SELF-ADMINISTERED MEDICATIONS LIST
|
|
|
- Alan Page
- 5 years ago
- Views:
Transcription
1 SELF-ADMINISTERED MEDICATIONS LIST Table of Contents Page Last Updated: January 23, 2019 INSTRUCTIONS FOR USE... 1 APPLICABLE CODES... 1 Related Commercial Policy LIST HISTORY/REVISION INFORMATION... 5 Self-Administered Medications INSTRUCTIONS FOR USE This Drug List provides assistance in interpreting UnitedHealthcare benefit plans. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Drug Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Drug Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Drug Policy. Other Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary. This Drug Policy is provided for informational purposes. It does not constitute medical advice. APPLICABLE CODES Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable. This Self-Administered Medication List identifies medications that are usually self-administered and excluded from payment under a standard medical benefit plan. See the Medical Benefit Drug Policy titled Self-Administered Medications for additional details. Any applicable clinician administered dosage formulations (e.g., intravenous infusion) of the drugs listed below may be covered under the medical benefit. Medication/Brand Name Description/Generic Name HCPCS Code(s) Chronically used drugs delivered by other routes of administration such as oral, suppositories, and topical medications are all considered to be usually self-administered Any non-chemotherapeutic/transplant medication with the ability for the patient to self-administer for chronic use Prescription drug, oral, nonchemotherapeutic, not otherwise specified J8499 Actemra (tocilizumab) subcutaneous Unclassified biologics Actimmune (interferon gamma-1b) Aimovig (erenumab) Ajovy (fremanezumab-vfrm) Amjevita (adalimumab-atto) Apokyn (apomorphine) Injection, interferon, gamma 1-b, 3 million units Injection, apomorphine hydrochloride, 1 mg (after first dose under medical supervision) J9216 J0364 Arcalyst (rilonacept) Injection, rilonacept, 1 mg J2793 Arikayce (amikacin) Prescription drug, oral, nonchemotherapeutic, Not Otherwise Specified UnitedHealthcare Commercial Medical Benefit Drug List J8499 Arixtra (fondaparinux) Injection, fondaparinux sodium, 0.5 mg J1652 Self-Administered Medications List Page 1 of 5
2 Avonex, Avonex Pen (interferon beta-1a) Injection, interferon beta-1a, 1 mcg for intramuscular use Q3027 Benlysta (belimumab) subcutaneous Unclassified biologics Betaseron (interferon beta-1b) Injection, interferon beta-1b, 0.25 mg J1830 Bethkis (tobramycin inhalation) Tobramycin, inhalation solution, FDAapproved final product, non-compounded, unit dose form, administered through DME, per 300 milligrams J7682 Bravelle (urofollitropin) Injection, urofollitropin, 75 iu J3355 Brovana (aformoterol) Bydureon (exanatide) Byetta (exanatide) Cayston (aztreonam lysine) Arformoterol, inhalation solution, FDAapproved final product, non-compounded, administered through DME, unit dose form, 15 NOC drugs, inhalation solution administered through DME J7605 J7699 Cimzia (certolizumab pegol) Injection, certolizumab pegol, 1 mg J0717 Copaxone, Glatopa, glatiramer (glatiramer acetate) Cosentyx (secukinumab) Cyltezo (adalimumab-adbm) Dupixent (dupilumab) Injection, glatiramer acetate, 20 mg J1595 Egrifta (tesamorelin Acetate) Unclassified drugs Emgality (galcanezumab-gnlm) Enbrel (etanercept) Injection, etanercept, 25 mg J1438 Erelzi (etanercept-szzs) Extavia (interferon beta-1b) Injection, interferon beta-1b, 0.25 mg J1830 Firazyr (icatibant ) Injection, icatibant, 1 mg J1744 Firmagon (degarelix) Injection, degarelix, 1 mg J9155 Follistim AQ (follitropin beta) Follitropin beta S0128 Forteo (teriparatide) Injection, teriparatide, 10 mcg J3110 Fragmin (dalteparin sodium) Injection, dalteparin sodium, per 2,500 IU J1645 Fuzeon (enfuvirtide) Injection, enfuvirtide, 1 mg J1324 Ganirelix acetate Gattex (teduglutide) Gonal-f (all formulations) (follitropin alfa) Injection, ganirelix acetate, 250 mcg Follitropin alpha S0132 S0126 Self-Administered Medications List Page 2 of 5
3 H.P. ACTHAR (corticotropin) Injection, corticotropin, up to 40 units (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is selfadministered) J0800 Haegarda (c-1 esterase inhibitor) Hemlibra (emicizumab) Humatrope, Genotropin, Omnitrope, Saizen, Zorbtive, Zomacton, Norditropin, Nutropin, Tev-tropin (somatropin) Injection, c-1 esterase inhibitor (human), Haegarda, 10 units Injection, somatropin, 1 mg J2941 Humira (adalimumab) Injection, adalimumab, 20 mg J0135 Ilumya (tildrakizumab) Imitrex (sumatriptan succinate) Injection, sumatriptan succinate, 6 mg J3030 Increlex, Iplex (mecasermin) Injection, mecasermin, 1 mg J2170 Innohep (tinzaparin sodium) Injection, tinzaparin sodium, 1000 IU J1655 Intron -A (interferon alfa-2b) Kevzara (sarilumab) Injection, interferon, alfa-2b, recombinant, 1 million units J9214 Kineret (anakinra) Unclassified biologics Kynamro (mipomersen sodium) Lantus (insulin glargine) Insulin, long acting; 5 units S5553 S5571 Leuprolide acetate, leuprolide acetate inj Leuprolide acetate, per 1 mg J9218 Levemir (insulin detemir) Lovenox (enoxaparin sodium) Injection, enoxaparin sodium, 10 mg J1650 Menopur, Repronex (menotropins) Myalept (metreleptin) Natpara (parathyroid hormone) Orencia (abatacept) (subcutaneous) Otrexup, Rasuvo (Methotrexate - Solution Auto-injector) Injection, menotropins, 75 iu Injection, abatacept, 10 mg Unclassified biologics S0122 J3950 J0129 Ovidrel (choriogonadotropin alpha) Unclassified drugs Ozempic (semaglutide) Palynziq (pegvaliase) Pegasys (interferon alfa-2a, pegylated) Pegintron (Peginterferon Alfa-2b) Injection, pegylated interferon alfa-2a, 180 mcg per ml Injection, pegylated interferon alfa-2a, 180 mcg per ml S0145 S0148 Self-Administered Medications List Page 3 of 5
4 Perforomist (formoterol fumarate) Formoterol fumarate, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 20 J7606 Plegridy (Peginterferon beta-1a) Praluent (alirocumab) Pregnyl, Novarel (chorionic gonadotropin) Pulmozyme (dornase alfa) Rebif (Interferon beta-1a) Injection, chorionic gonadotropin, per 1,000 USP units Dornase alfa, inhalation solution, FDAapproved final product, non-compounded, administered through DME, unit dose form, per milligram Injection, interferon beta-1a, 1 mcg for subcutaneous use J0725 J7639 Q3028 Relistor (methylnaltrexone) Injection, methylnaltrexone, 0.1 mg J2212 Repatha (evolucumab) Ruconest (c-1 esterase inhibitor, recombinant) Sandostatin (octreotide acetate) subcutaneous Signifor (pasireotide) Siliq (brodalumab) Simponi (golimumab) Soliqua (insulin glargine/lixisenatide) Somavert (pegvisomant) Stelara (ustekinumab) Strensiq (asfotase alfa) Injection, c-1 esterase inhibitor (recombinant), Ruconest, 10 units Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg Ustekinumab, for subcutaneous injection, 1 mg J0596 J2354 J3357 Sumatriptan succinate Injection, sumatriptan, succinate, 6 mg J3030 Sumavel (sumatriptan succinate) Injection, sumatriptan, succinate, 6 mg J3030 Sylatron (peginterferon alfa-2b) Peginterferon alfa-2b J9999 Symlin (pramlintide acetate) Unclassified drugs Symlin, symlinpen 60, symlinpen 120 (Pramlintide acetate) Synribo (omacetaxine mepesuccinate) Unclassified drugs Injection, omacetaxine mepesuccinate, 0.01 mg J9262 Takhzyro (lanadelumab-flyo) Taltz (ixekizumab) Tanzeum (albiglutide) Self-Administered Medications List Page 4 of 5
5 Tegsedi (inotersen) Unclassified drugs Toujeo (Insulin glargine) Toujeo solostar (insulin glargine) Insulin delivery device, disposable pen (including insulin); 1.5 ml size S5570 Tremfya (guselkumab) Trulicity (dulaglutide) Tymlos (abaloparatide) Tyvaso (treprostinil) Ventavis (iloprost) Xultophy, Victoza, Saxenda (liragludtide) Xyosted (testosterone enanthate) Zembrace (sumatriptan succinate) Treprostinil, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 1.74 mg Iloprost, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 20 J7686 Q4074 LIST HISTORY/REVISION INFORMATION Date Action/Description 01/23/2019 Added Xyosted (testosterone enanthate) (HCPCS codes and ) 01/01/ /01/2018 Updated list of applicable HCPCS codes to reflect annual code edits; removed C9015 and C9029 New list; refer to the Medical Benefit Drug Policy titled Self-Administered Medications for complete details Self-Administered Medications List Page 5 of 5
Exclusion Reasons Presumption of Long- Term Non-Acute Administration C9399 Unclassified Drugs or
Noridian Healthcare Solutions, LLC Jurisdiction F Part B Self-Administered Drug (SAD) Exclusion List (A53033); Effective 8/7/2017 The following medications are considered self-administered and are not
Descriptor Brand Name. Alprostadil, Caverject, Edex, Prostin VR Pediatric. Calcimar, Miacalcin
Self-Administered Drug Exclusion List R2 This article from Medicare A News, Issue 2106 dated January 23, 2013 and Medicare B News, Issue 283 dated January 23, 2013 is being revised to add Acthar ACTH gel
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
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
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
2019 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS) MEASURE TYPE: Process
Quality ID #337: Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier National Quality Strategy Domain:
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
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
Formulary Changes. One mission: you TABLE A. FORMULARY CHANGES 7/1/2018: Commercial 3-Tier Formulary. Commercial 4-Tier Formulary
One mission: you Changes July 1, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for
TRICARE Uniform Formulary. Pre-Authorization Requirements
TRICARE Uniform Formulary Pre-Authorization Requirements The Department of Defense (DoD) requires pre-authorization on select medications. These medications are on the DoD s pre-authorization list because
2019 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS) MEASURE TYPE: Outcome High Priority
Quality ID #410: Psoriasis: Clinical Response to Systemic Medications National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Meaningful Measure Area: Management of Chronic
Cosentyx. Cosentyx (secukinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.11 Subject: Cosentyx Page: 1 of 7 Last Review Date: September 20, 2018 Cosentyx Description Cosentyx
Regulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 8 Last Review Date: March 16, 2018 Orencia Description Orencia (abatacept)
Medical Policy An independent licensee of the Blue Cross Blue Shield Association
Otezla (apremilast) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Otezla (apremilast) Prime Therapeutics will review Prior Authorization requests Prior
Self-Injected Medications and Disposal Recommendations
Actimmune (interferon gamma 1b) Apokyn (apomorphine hydrochloride) Arixtra (fondaparinux) Avonex (interferon beta 1a) Betaseron (interferon beta 1b) Copaxone (glatiramer acetate) Edex (alprostadil) InterMune
Regulatory Status FDA-approved indications: Entyvio is an α4β7integrin receptor antagonist indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.12 Subject: Entyvio Page: 1 of 7 Last Review Date: September 20, 2018 Entyvio Description Entyvio
Regulatory Status FDA-approved indication: Orencia is a selective T cell co-stimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Orencia Page: 1 of 9 Last Review Date: September 20, 2018 Orencia Description Orencia (abatacept)
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary Biologic Immunomodulators Prior Authorization with Quantity Limit (with a preferred option) OBJECTIVE The intent of the
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
ACTEMRA (tocilizumab)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 1. Active Polyarticular Juvenile Idiopathic Arthritis (PJIA) b. Patient has an intolerance or has experienced
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
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
CIMZIA (certolizumab pegol)
Pre - PA Allowance None Prior-Approval Requirements Age Diagnoses 18 years of age or older Patient must have ONE of the following: 1. Moderate to severe Crohn s Disease (CD) a. Inadequate response, intolerance
Stelara. Stelara (ustekinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.04 Subject: Stelara Page: 1 of 9 Last Review Date: September 20, 2018 Stelara Description Stelara
Cimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.11 Section: Prescription Drugs Effective Date: April 1, 2018 Subject: Cimzia Page: 1 of 5 Last Review
Clinical Policy: Infertility Therapy Reference Number: CP.CPA.261 Effective Date: Last Review Date: Line of Business: Medicaid Medi-Cal
Clinical Policy: Reference Number: CP.CPA.261 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important Reminder at the end of this policy for important
RHEUMATOID ARTHRITIS DRUGS
Rheumatology Biologics Criteria from the Exceptional Access Program RHEUMATOID ARTHRITIS DRUGS DRUG NAME BRS REIMBURSED DOSAGE FORM/ STRENGTH Adalimumab Humira 40 mg/0.8 syringe and 40mg/0.8 pen for Anakinra
Otezla. Otezla (apremilast) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Otezla Page: 1 of 5 Last Review Date: March 16, 2018 Otezla Description Otezla (apremilast) Background
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
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
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Infertility Injectables Table of Contents Coverage Policy... 1 General Background...16 Coding/Billing Information...20 References...20 Effective Date...
Thank you for your request for information that has been processed under reference number
Corporate Development Contact us: dhft.foi@nhs.net Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Tel: 01332 265500 Minicom: 01332 785566 www.derbyhospitals@nhs.uk Follow us on Twitter @DerbyHospitals
Corporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: abatacept_orencia 4/2008 2/2018 2/2019 2/2018 Description of Procedure or Service Abatacept (Orencia ), a
UnitedHealthcare Pharmacy Clinical Pharmacy Programs
Program Number 2017 P 3041-8 Program Step Therapy Medications UnitedHealthcare Pharmacy Clinical Pharmacy Programs *Orencia (abatacept) *This step criteria refers to the subcutaneous formulation of abatacept
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
Xeljanz. Xeljanz, Xeljanz XR (tofacitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.24 Subject: Xeljanz Page: 1 of 6 Last Review Date: March 16, 2018 Xeljanz Description Xeljanz, Xeljanz
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
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
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
Specialty Pharmacy Pipeline
Specialty Pharmacy Pipeline Drugs to Watch Anticipated Launches Q1 Q2 2017 Atopic Dermatitis Dupixent (dupilumab) Subcutaneous injection Regeneron Pharmaceuticals/Sanofi moderate-to-severe atopic dermatitis
Corporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: golimumab_simponi 8/2013 2/2018 2/2019 3/2018 Description of Procedure or Service Golimumab (Simponi and
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
Drug Therapy Guidelines
Drug Therapy Guidelines Applicable Medical Benefit Effective: 8/15/18 Pharmacy- Formulary 1 x Next Review: 6/18 Pharmacy- Formulary 2 x Date of Origin: 7/00 Injectable Fertility Medications: Bravelle,
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
Clinical Policy: Natalizumab (Tysabri) Reference Number: ERX.SPA.162 Effective Date:
Clinical Policy: (Tysabri) Reference Number: ERX.SPA.162 Effective Date: 10.01.16 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
Drug Therapy Guidelines
Drug Therapy Guidelines Applicable Injectable Fertility Medications: Bravelle, Cetrotide, Follistim AQ, Ganirelix, Gonal-F, human chorionic gonadotropin, leuprolide, Menopur, Novarel, Ovidrel, Pregnyl,
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
Regulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 9 Last Review Date: March 16, 2018 Simponi / Simponi
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
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
Biologics for Autoimmune Diseases
Biologics for Autoimmune Diseases Goal(s): Restrict use of biologics to OHP funded conditions and according to OHP guidelines for use. Promote use that is consistent with national clinical practice guidelines
Prescription benefit updates Large group
Prescription benefit updates Large group Moda Health s prescription program is a pharmacy benefit that offers members a choice of safe effective medication treatments. The program also helps you save money
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
ART Drugs. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.30.02 Subject: ART Drugs Page: 1 of 7 Last Review Date: September 15, 2017 ART Drugs Description Bravelle
HEALTHTEAM ADVANTAGE 2018 Step Therapy Criteria
GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level 1 agent (LANTUS, LEVEMIR,
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS
5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda
Pulmonary Hypertension Weight Loss Skin Conditions. Skin Conditions Multiple Sclerosis Endocrine Disorder. Endocrine Disorder.
Prior Authorization PricewaterhouseCoopers The following medications may require prior authorization prior to dispensing at a participating retail pharmacy or through the Express Scripts Pharmacy home
Actemra. Actemra (tocilizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.12 Subject: Actemra Page: 1 of 13 Last Review Date: September 20, 2018 Actemra Description Actemra
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,
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,
UPMC for You Pharmacy and Therapeutics Committee Meeting April 7, 2014 meeting
UPMC for You Pharmacy and Therapeutics Committee Meeting April 7, 2014 meeting 1. Call to order: The meeting was called to order at 7:05 a.m. 2. Review of the minutes: The minutes of the January meeting
Subject: Guselkumab (Tremfya ) Injection
09-J2000-87 Original Effective Date: 09/15/17 Reviewed: 09/12/18 Revised: 01/01/19 Subject: Guselkumab (Tremfya ) Injection THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
ACTEMRA (TOCILIZUMAB) INJECTION FOR INTRAVENOUS INFUSION
ACTEMRA (TOCILIZUMAB) INJECTION FOR INTRAVENOUS INFUSION UnitedHealthcare Oxford Clinical Policy Policy Number: PHARMACY 284.9 T2 Effective Date: June 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE...
OptumRx Focused Utilization Management Program
Utilization management updates - January 1, 2019 OptumRx Focused Utilization Management Program OptumRx focused step therapy with quantity limits programs If you have a prescription for any of the Step
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Tysabri) Reference Number: HIM.PA.SP17 Effective Date: 05.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Coding Implications Revision Log See Important Reminder
1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review
ART Drugs. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.08.02 Subject: ART Drugs Page: 1 of 7 Last Review Date: December 3, 2015 ART Drugs Description Bravelle
ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
Mountain Health Trust/WV Health Bridge
Mountain Health Trust/WV Health Bridge Preferred Drug List (PDL) The West Virginia Preferred Drug List (PDL) is a list of medications recommended to BMS by the West Virginia Medicaid Pharmaceutical and
INFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 6 years of age or older 1. Moderate to severe Crohn s disease (CD) a. Patient has fistulizing disease
Clinical Policy: Mitoxantrone (Novantrone) Reference Number: CP.CPA.334 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: (Novantrone) Reference Number: CP.CPA.334 Effective Date: 06.01.18 Last Review Date: 05.18 Line of Business: Commercial Coding Implications Revision Log See Important Reminder at the end
Subject: Ixekizumab (Taltz ) Injection
09-J2000-62 Original Effective Date: 06/15/16 Reviewed: 09/12/18 Revised: 10/15/18 Subject: Ixekizumab (Taltz ) Injection THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
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
HEALTHTEAM ADVANTAGE 2018 Step Therapy Criteria
GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML HEALTHTEAM ADVANTAGE Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level
Pharmacy Management Drug Policy
SUBJECT: Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs POLICY NUMBER: PHARMACY-73 EFFECTIVE DATE: 01/01/2018 LAST REVIEW DATE: 06/11/2018 If the member s subscriber
MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 04/09/18 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: 09/05/18 ARCHIVE DATE:
ILARIS (canakinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
Drug Name Generic Name J-Code Unclassified Drugs in excess of $10,000
Unclassified Drugs in excess of $10,000 J3490 Unclassified Biologics in excess of $10,000 J3590 Revenue Codes in excess of $10,000 R250 - R259 ABRAXANE paclitaxel protein-bound J9264 & J9267 ACTEMRA tocilizumab
Oregon Health Plan prescription benefit updates
Oregon Health Plan prescription benefit updates EOCCO s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps you save
Regulatory Status FDA-approved indication: Humira and its biosimilars are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-5)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 13 Last Review Date: November 30, 2018 Humira Description Humira (adalimumab),
Immune Modulating Drugs Prior Authorization Request Form
Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:
Center for Evidence-based Policy
P&T Committee Brief Targeted Immune Modulators: Comparative Drug Class Review Alison Little, MD Center for Evidence-based Policy Oregon Health & Science University 3455 SW US Veterans Hospital Road, SN-4N
Regulatory Status FDA-approved indication: Humira and Amjevita are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 14 Last Review Date: June 22, 2018 Humira Description Humira (adalimumab),
2017 Blue Cross and Blue Shield of Louisiana
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
Regulatory Status FDA-approved indication: Humira and Amjevita are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 13 Last Review Date: September 20, 2018 Humira Description Humira (adalimumab),
Regulatory Status FDA-approved indication: Enbrel and Erelzi are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.27 Subject: Enbrel Page: 1 of 10 Last Review Date: June 22, 2018 Enbrel Description Enbrel (etanercept),
ACTEMRA (TOCILIZUMAB) INJECTION FOR INTRAVENOUS INFUSION
ACTEMRA (TOCILIZUMAB) INJECTION FOR INTRAVENOUS INFUSION UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0043I Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
Background AN UPDATED LOOK AT TREATMENTS FOR PLAQUE PSORIASIS JULY 2018 PLAQUE PSORIASIS TARGETED IMMUNOMODULATORS AS A TREATMENT OPTION
JULY 2018 Background PLAQUE PSORIASIS Plaque psoriasis is a common disease affecting 3% of the US population that causes itchy, red, scaly, raised lesions on the skin, most commonly on the elbows, knees,
Subject: Vedolizumab (Entyvio ) Infusion
09-J2000-18 Original Effective Date: 09/15/14 Reviewed: 09/12/18 Revised: 01/15/19 Subject: Vedolizumab (Entyvio ) Infusion THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
UnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2018 P 2104-4 Program Prior Authorization/Medical Necessity Medication Taltz (ixekizumab) P&T Approval Date 8/2016, 5/2017, 2/2018 Effective
Ophthalmologic Policy. Vascular Endothelial Growth Factor (VEGF) Inhibitors
Ophthalmologic Policy UnitedHealthcare Commercial Drug Policy Vascular Endothelial Growth Factor (VEGF) Inhibitors Policy Number: 2016D0042H Effective Date: October 1, 2016 Table of Contents Page INSTRUCTIONS
Drug Name (specify drug) Quantity Frequency Strength
Prior Authorization Form GEHA FEDERAL - STANDARD OPTION Autoimmune Conditions (FA-PA) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
Clinical Policy: Natalizumab (Tysabri) Reference Number: CP.PHAR.259 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Tysabri) Reference Number: CP.PHAR.259 Effective Date: 07.01.16 Last Review Date: 05.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
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