2018 BCN Advantage Prior Authorization Criteria Last updated: April, 2018
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- Jody Alannah Allen
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1 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 Berinert Betaseron Bexarotene Bosulif Briviact Bydureon Byetta Cabometyx Calquence Cayston Cholbam Chorionic Gonadotropin Cimzia Cinryze Clomipramine Cometriq Copaxone Cotellic Crinone Cyramza Daliresp Darzalex Doxepin Duopa Dysport Empliciti Epclusa Epogen Erivedge Esbriet Estradiol Extavia Farydak Fentanyl Oral Fentora Firazyr Forteo Gattex Genotropin Gilenya Gilotrif Glassia Harvoni Hetlioz Humatrope Ibrance Iclusig Idhifa Ilaris Imbruvica Imfinzi Imipramine Increlex Inflectra Inlyta Jakafi Juxtapid Kalydeco Kanuma Kineret Kisqali Kisqali Femara Korlym Kuvan Kynamro Kyprolis Lartruvo Lazanda Lenvima Letairis Lidocaine Transdermal Linzess Lonsurf Lynparza Mavyret Mekinist Menest Modafinil Movantik Mozobil Myalept Mylotarg Natpara Nexavar Nerlynx Ninlaro Norditropin Novarel Nuplazid Nutropin Nutropin Aq Odomzo Ofev Omnitrope Opsumit Orencia, Orencia Clickject Orenitram Orkambi Otezla Oxandrolone Oxymetholone Pegasys Plegridy Pomalyst Praluent Procrit Procysbi Prolastin C Prolia Promacta Radicava Ravicti Rebif Relistor Remicade Remodulin Repatha Revatio Revlimid Rubraca Rydapt Saizen Samsca Serostim Sildenafil Simponi Sirturo Somavert Sovaldi Sprycel Stelara Strensiq Subsys Sutent Sylatron Sylvant SymlinPen Tabloid Tafinlar Tagrisso Tarceva Targretin Tasigna Tecentriq Tecfidera Testim Testosterone Tetrabenazine Thalomid Thioridazine Tracleer Treanda Trimipramine Tysabri Uptravi Vecamyl Vectibix Vemlidy Venclexta Verzenio Victoza Vosevi Votrient Xalkori Xeljanz Xgeva Xolair Xtandi Xyrem Yondelis Yervoy Zaleplon Zelboraf Zemaira Zejula Zolinza Zorbtive Zurampic Zydelig Zykadia Zytiga 1 of 88 H5883_Ph_Apr18PAlist_NM
2 Actemra Required med info Prescriber restrictions Prescribing physician is a rheumatologist Coverage duration One Year Requires trial of etanercept (Enbrel) and adalimumab (Humira) when these medications are FDA labeled for the Part D coverable medically accepted indication. Adempas Required med info Prescriber restrictions 2 of 88
3 Afinitor Required med info Prescriber restrictions Prescriber is an oncologist Coverage is not provided when Affinitor is used in combination with Nexavar or Sutent Aliqopa Effective Date: March 1, 2018 Required med info Prescriber restrictions Coverage duration One year 3 of 88
4 Alecensa Required med info Prescriber restrictions Coverage duration Lifetime Alunbrig Required med info Prescriber restrictions 4 of 88
5 Amitzia Required med info Diagnosis: 1. Chronic idiopathic constipation (CIC) in adults or 2. Opioid induced constipation in adults with chronic, non cancer pain or 3. Irritable bowel syndrome (IBS) with constipation in women Age restrictions 18 years of age and older Prescriber restrictions Ampyra Documentation of trial/failure within the last 12 months of: 1. A fiber laxative and 2. One of the following: a stimulant laxative or an osmotic laxative Exclusion criteria Patients with a history of seizure or moderate to severe renal impairment defined by a crcl of 50ml/min or less Required med info Initial requests require documentation of a 25 foot timed walk test. Renewal requests require documentation of improvement in walking distance of a 25 foot timed walk test compared to pretreatment. Prescriber restrictions Prescriber is a neurologist Coverage duration INITIAL = Three Months RENEWAL = One Year 5 of 88
6 Initial coverage is provided to improve walking distance in patients with a diagnosis of multiple sclerosis who have the ability to walk a timed 25 foot walk test. renewal criteria: documentation that the member has shown an improvement in walking distance of a 25 foot timed walk test compared to pretreatment. Transdermal Androgens Androgel, Androderm, Testim, Testipel, Testosterone Required med info Documentation of androgen deficiency syndrome confirmed by two morning testosterone levels less than 300 ng/dl and at least 2 clinical signs or symptoms specific to androgen deficiency Prescriber restrictions 6 of 88
7 ALPHA-1-PROTEINASE INHIBITOR (Aralast NP, Glassia, Prolastin C, Zemaira) Required med info Prescriber restrictions Arcalyst Required med info Age restrictions 12 years of age and older Prescriber restrictions 7 of 88
8 Aubagio Required med info Prescriber restrictions Avonex Required med info Prescriber restrictions Coverage duration Lifetime 8 of 88
9 Bavencio Required med info Prescriber restrictions Coverage duration Lifetime Beleodaq Required med info Prescriber restrictions 9 of 88
10 Berinert Required med info Prescriber restrictions Prescribing physician is an immunologist or hematologist Betaseron Required med info Prescriber restrictions Coverage duration Lifetime 10 of 88
11 Bosulif Required med info Prescriber restrictions Briviact Required med info Prescriber restrictions 11 of 88
12 Cabometyx Required med info Prescriber restrictions Calquence Effective Date: March 1, 2018 Required med info Prescriber restrictions 12 of 88
13 Cayston Required med info Prescriber restrictions Cayston is subject to Part B versus Part D coverage review Cholbam Required med info Prescriber restrictions 13 of 88
14 Chorionic Gonadotropin Required med info Prescriber restrictions 14 of 88
15 Cimzia Required med info Requires documentation of diagnosis and medication history or intolerance(s) Prescriber restrictions Crohn's Disease: Prescribed or recommended by a gastroenterologist RA: Prescribed or recommended by a rheumatologist. Rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis requires the member has tried and failed Humira and Enbrel, except if not tolerated due to documented clinical side effects. Crohn's disease, requires: 1) treatment with an adequate course of systemic corticosteroids (e.g., 40 mg to 60 mg prednisone per day for 7 to 14 days) has been ineffective or is contraindicated or 2) the patient has been unable to taper off an adequate course of systemic corticosteroids without experiencing worsening of disease or 3) the patient is experiencing breakthrough disease (e.g., active disease flares) while stabilzed for at least 2 months on an immunomodulatory medication (such as azathioprine, mercaptopurine, cyclosporine, or methotrexate) and 4) adalimumab (Humira) is not effective after at least an initial 3 dose induction period, except if not tolerated due to documented clincial side effects. 15 of 88
16 Cinryze Required med info Prescriber restrictions Prescribed by an immunologist, allergist, or rheumatologist Cometriq Required med info Prescriber restrictions 16 of 88
17 Copaxone Required med info Prescriber restrictions Coverage duration Lifetime Cotellic Required med info Prescriber restrictions Coverage duration Lifetime 17 of 88
18 Crinone Required med info Prescriber restrictions Cyramza Required med info Prescriber restrictions Coverage duration Lifetime 18 of 88
19 Daliresp Required med info Diagnosis and patient medication history Prescriber restrictions Coverage is provided for the treatment of severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis in patients with a history of exacerbations and patient is receiving: 1. inhaled long acting beta 2 agonist [for example, Formoterol, Salmeterol] AND 2. inhaled long acting anticholinergic agent [for example, Tiotropium] AND 3. inhaled corticosteroid [for example, Fluticasone] OR 4. Patient experienced intolerance or has contraindications to use of these medications Darzalex Required med info Prescriber restrictions Coverage duration Lifetime 19 of 88
20 Duopa Required med info Prescriber restrictions Subject to Part B versus D coverage review. Duopa may be covered under Medicare Part B if the patient is receiving enteral suspension administered as a continuous infusion using a portable infusion pump. It may be covered under Medicare Part D if the patient is receiving enteral suspension short term via a naso jejunal tube 20 of 88
21 Dysport Exclusion criteria Will not be covered for cosmetic purposes Required med info Prescriber restrictions Empliciti Required med info Prescriber restrictions Coverage duration Lifetime 21 of 88
22 Epclusa Required med info CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE Prescriber restrictions Coverage duration CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE Erythropoesis Stimulating Agents: Aranesp, Epogen, Procrit Required med info Prescriber restrictions Coverage duration 3 months Erythropoesis stimulating agents are subject to Part B vs Part D review. 22 of 88
23 Erivedge Required med info Prescriber restrictions Prescribed by or in consultation with a dermatologist or oncologist Esbriet Required med info Prescriber restrictions 23 of 88
24 Estrogens (Estradiol, Menest) Required med info Age restrictions Authorization is required for members 65 years of age and older Prescriber restrictions Oral Estrogen (Menest) will be approved when used as part of a cancer treatment regimen. For all other uses, Menest will be approved if two of the following safer alternatives as been tried and failed or are not appropriate or contraindicated. Safer alternatives include: e.g., SSRIs, venlafaxine ER, Premarin vaginal cream, Estrace vaginal creams, Estring or Femring Vaginal Rings, Vagifem vaginal tablets 24 of 88
25 Extavia Required med info Prescriber restrictions Coverage duration Lifetime Farydak Required med info Prescriber restrictions 25 of 88
26 Firazyr Covered uses Exclusion criteria Required med info Age restrictions Prescriber restrictions Coverage duration For acute attacks of hereditary angioedema (HAE). All FDA approved indications not otherwise excluded from Part D. 18 years of age or older Prescribing physician is an immunologist or hematologist One Year Forteo Exclusion criteria Coverage is not provided for hypocalcemia Required med info Prescriber restrictions Coverage duration One year with maximum two years of therapy Requires patient has tried and failed at least one bisphosphonate except when: 1. Contraindication to an oral and intravenous bisphosphonate (such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration) 2. Documented intolerance to a bisphosphonate 26 of 88
27 Gattex Required med info Prescriber restrictions Coverage duration Lifetime Gilenya Required med info Prescriber restrictions 27 of 88
28 Giltorif Required med info Prescriber restrictions Harvoni Required med info Prescriber restrictions Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance Criteria will be applied consistent with current AASLD/IDSA guidance 28 of 88
29 Growth Hormone: Genotropin, Humatrope, Increlex, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Somavert, Zorbtive Required med info Covered for the replacement of endogenous growth hormone in adults with growth hormone deficiency of childhood onset or adult onset. Covered if initial diagnosis based on two growth hormone stimulation tests and that the patient does not have edema, arthralgias, or carpal tunnel syndrome. Serostim is covered for aids wasting cachexia. Norditropin is covered for Noonan syndrome, Turner syndrome, and adult growth hormone deficiency. Nutropin is covered for Turner syndrome, and adult growth hormone deficiency. Omnitrope and Saizen are covered for adult growth hormone deficiency. Zorbtive is covered for the treatment of short bowel syndrome in patients receiving specialized nutritional support. Somavert is covered for acromegaly. Prescriber restrictions 29 of 88
30 Hetlioz Required med info Documentation of patient visual capabilities Prescriber restrictions Coverage duration Lifetime Hepatitis Treatments: Pegasys, Pegasys proclick Required med info Documentation of concomitant Ribavarin use (or contraindications) is required when requesting initial use for Hepatitis C. Documentation of viral genotype is required for Hepatitis C. Documentation of response to therapy is required for requests for continuation of therapy for Hepatitis C Prescriber restrictions Coverage duration Initiation of Therapy: 12 weeks Continuation Therapy: 24 to 48 weeks 30 of 88
31 High Risk in the Elderly Medications: High Risk in the Elderly Drugs: Tricyclic Antidepressants: Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine Required med info Age restrictions Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions High Risk Tricyclic Antidepressants are approved if patient has a history of use. For patients initiating therapy, the high risk tricyclic antidepressant is approved if at least one of the suggested alternatives (nortriptyline, desipramine, citalopram, escitalopram, mirtazapine, sertraline, venlafaxine) with less sedation and fewer anticholinergic effects have been tried and failed or is not appropriate or contraindicated for the intended use. 31 of 88
32 High Risk in the Elderly Medications: Zaleplon Required med info Age restrictions Authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions Lunesta (Zaleplon) is approved if at least one of the suggested alternatives, (low dose Trazodone (25 50mg) or Rozerem), has been tried and failed or is not appropriate or contraindicated for the intended use. High Risk in the Elderly Medications: Thioridiazine Required med info Age restrictions Prior authorization is required for formulary high risk medications for members 65 years of age and older Prescriber restrictions Thioridizine is covered for patients who have a history of use. For patients initiating therapy, thioridizine is covered if patient has a failure of or intolerance to at least one other safer alternative antipsychotic such as aripiprazole or quetiapine. 32 of 88
33 Ibrance Required med info Prescriber restrictions Iclusig Required med info Prescriber restrictions 33 of 88
34 Idhifa Effective Date: March 1, 2018 Required med info Prescriber restrictions Ilaris Required med info Requires documentation of diagnosis. Prescriber restrictions 34 of 88
35 Imbruvica Required med info Prescriber restrictions Imfinzi Required med info Prescriber restrictions 35 of 88
36 Inflectra Required med info Prescriber restrictions 36 of 88
37 Injectable Diabetic Medications: Byetta, Bydureon, Victoza, SymlinPen Exclusion criteria Not covered for non Type 2 diabetes diagnosis. Not covered for weight loss in patients with or without diabetes. Required med info Prescriber restrictions Coverage duration Lifetime Byetta, Bydureon, Victoza: Approved as adjunctive therapy to improve glycemic control in patients who have a diagnosis of Type II Diabetes Mellitus and are currently taking or have tried and failed at least One of the following: Metformin, a Sulfonylurea, or a Thiazolidinedione, or One of the following: a combination of metformin and a sulfonylurea or a combination of Metformin and a Thiazolidinedione. SymlinPen is covered for patients that have failed intensive treatment with insulin monotherapy and for concurrent use with an insulin product 37 of 88
38 Inlyta Exclusion criteria Coverage is not provided for combination use with other tyrosine kinase inhibitors such as Sorafenib, Sunitinib Required med info Coverage for the treatment of renal cell carcinoma is provided after failure with one prior systemic therapy Prescriber restrictions Jakafi Required med info Prescriber restrictions Prescribed by a hematologist / oncologist 38 of 88
39 Juxtapid Required med info Requires documentation of diagnosis of homozygous familial hypercholesterolemia. Age restrictions Prescriber restrictions Coverage duration Lifetime Requires trial and failure of Kynamro Kalydeco Required med info Prescriber restrictions Coverage duration Lifetime 39 of 88
40 Kanuma Required med info Prescriber restrictions Kineret Required med info Prescriber restrictions Rheumatoid arthritis requires a treatment failure or contraindication to Enbrel or Humira. 40 of 88
41 Kisqali, Kisqali Femara Required med info Prescriber restrictions Korlym Required med info Prescriber restrictions 41 of 88
42 Kynamro Required med info Prescriber restrictions Coverage duration Lifetime Kyprolis Required med info Prescriber restrictions Coverage duration Lifetime 42 of 88
43 Lartruvo Effective Date: March 1, 2018 Required med info Prescriber restrictions Coverage duration Lifetime Lenvima Required med info Prescriber restrictions 43 of 88
44 Lidocaine Transdermal Patch Required med info Prescriber restrictions Linzess Required med info Prescriber restrictions Chronic idiopathic constipation (CIC) requires documentation of failure within the last 12 months of use of a fiber laxative and one of the following: a stimulant laxative or an osmotic laxative. Drug induced constipation must be ruled out. 44 of 88
45 Lonsurf Required med info Prescriber restrictions Coverage duration Lifetime Lynparza Required med info Prescriber restrictions 45 of 88
46 Mavyret Effective Date: March 1, 2018 Required med info Prescriber restrictions Mekinist Required med info Confirmation of the presence of BRAF V600E or V600K mutation in tumor specimen Prescriber restrictions 46 of 88
47 Modafinil, Armodafinil Required med info Prescriber restrictions Movantik Required med info Prescriber restrictions 47 of 88
48 Mozobil Required med info Prescriber restrictions Coverage duration Duration requested up to one month Myalept Exclusion criteria Coverage is not provided for the following: general obesity, HIV related lipodystrophy, partial lipodystrophy, metabolic disease (without concurrent generalized lipodystrophy) or liver disease. Required med info Diagnosis of congenital or acquired generalized lipodystrophy Prescriber restrictions Prescribing physician is an endocrinologist Coverage duration Initial = 3 months Renewal = 1 year 48 of 88
49 Mylotarg Effective Date: March 1, 2018 Required med info Prescriber restrictions Narcotic Analgesics: Abstral, Fentanyl Citrate Oral Transmucosal, Fentora, Lazanda, Onsolis, Subsys Required med info Requires documentation of diagnosis and medication history Prescriber restrictions Covered for cancer or cancer related diagnosis in patients already receiving long acting opioids 49 of 88
50 Natpara Required med info Prescriber restrictions Nerlynx Effective Date: March 1, 2018 Required med info Prescriber restrictions 50 of 88
51 Nexavar Required med info Prescriber restrictions Hepato cellular carcinoma: Prescribed by an oncologist, hepatologist, or gastroenterologist All other indications: Prescribed by an oncologist Ninlaro Required med info Prescriber restrictions Coverage duration Lifetime 51 of 88
52 Nuplazid Required med info Prescriber restrictions Odomzo Required med info Prescriber restrictions Coverage duration Lifetime 52 of 88
53 Ofev Required med info Prescriber restrictions Coverage duration One year Orencia, Orencia Clickject Required med info Prescriber restrictions Coverage is provided when there has been a trial and failure or contraindication to Enbrel or Humira 53 of 88
54 Orenitram Required med info Prescriber restrictions Coverage duration Lifetime Orkambi Required med info Prescriber restrictions Coverage duration Lifetime 54 of 88
55 Otezla Required med info Prescriber restrictions Coverage is provided for moderate to severe plaque psoriasis or psoriatic arthritis when there has been a trial and failure or contraindication to Enbrel or Humira Oxandrolone Covered uses Exclusion criteria Required med info Age restrictions Prescriber restrictions Coverage duration All medically accepted indications not otherwise excluded from Part D One Year 55 of 88
56 Oxymetholone, Anadrol-50 Exclusion criteria Coverage will not be provided if anabolic steroids are used to enhance athletic performance or for anti aging purposes Required med info Oxymetholone: Documentation that use is 1) for therapy to offset protein catabolism associated with prolonged use of corticosteroids. 2) for bone pain associated with osteoporosis. 3) as prophylactic therapy in patients with hereditary angioedema. anadrol 50 requires documentation of:1) HIV associated wasting.2) prophylactic therapy for hereditary angioedema.3) clinically diagnosed anemia. Prescriber restrictions Plegridy Required med info Prescriber restrictions 56 of 88
57 Pomalyst Required med info Diagnosis of multiple myeloma Prescriber restrictions Coverage is provided if: 1) Patient has received at least two prior therapies including Lenalidomide and Bortezomib and 2) Demonstrated disease progression on or within 60 days of completion of the last therapy. Praluent Required med info Prescriber restrictions 57 of 88
58 Procysbi Required med info Prescriber restrictions Coverage duration Lifetime 58 of 88
59 Prolia Exclusion criteria Coverage is not provided for hypocalcemia Required med info Prescriber restrictions Prolia is subject to Part B versus Part D review Requirements: Patient has tried and failed at least one bisphosphonate except when: 1. Contraindication to a bisphosphonate (oral and intravenous) such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration 2. Documented intolerance to a bisphosphonate 59 of 88
60 Promacta Required med info Requires documentation of diagnosis, medication history or intolerance(s), platlet counts. Prescriber restrictions Prescribed or recommended by a hematologist, hepatologist or gastroenterologist. Coverage duration Initiation of therapy 12 week approval Continuation therapy 12 month approval Pulmonary Agents: Adcirca, Letairis, Opsumit, Revatio oral suspension, Sildenafil Citrate 20mg, Remodulin, Tracleer Required med info Prescriber restrictions Coverage for Revatio and Adcirca is not provided in situations where patients are receiving nitrate therapy. 60 of 88
61 Radicava Effective Date: March 1, 2018 Required med info Prescriber restrictions Ravicti Required med info Prescriber restrictions 61 of 88
62 Rebif Required med info Prescriber restrictions Coverage duration Lifetime Relistor Required med info Prescriber restrictions Coverage duration Three Months Requires adequate treatment consisting of 5 days duration of treatment of agents for constipation, including at least any two of the following: Bulk laxatives, saline laxatives or osmotic laxatives. Coverage may not be provided if there are contraindications to Methylnaltrexone therapy. 62 of 88
63 Remicade Required med info Verification that the patient has been evaluated for TB and treated accordingly Prescriber restrictions Remodulin Required med info Prescriber restrictions 63 of 88
64 Repatha Required med info Prescriber restrictions Revlimid Required med info Prescriber restrictions Prescribed by or in consultation with an oncologist or hematologist 64 of 88
65 Rubraca Required med info Prescriber restrictions Rydapt Required med info Prescriber restrictions 65 of 88
66 Samsca Required med info Documentation that patient does not have underlying liver disease Prescriber restrictions Coverage duration One Month Kuvan (Sapropterin hydrochloride) Required med info Prescriber restrictions Coverage duration Initial 2 months auth will be extended for 1 year if documented response after initial therapy Renewal criteria: after initial therapy of 2 months. a 30% or greater reduction in phenylalanine from baseline 66 of 88
67 Simponi Required med info Requires verification that the patient has been evaluated for TB and treated accordingly Prescriber restrictions For ulcerative colitis, coverage is provided when the member has tried and failed Humira unless contraindicated or not tolerated due to documented clinical side effects. All other indications for use require the member has tried and failed Humira and Enbrel, except if contraindicated or not tolerated due to documented clinical side effects. Sirturo Required med info Diagnosis Prescriber restrictions Must be used in combination with at least 3 other agents 67 of 88
68 Sovaldi Required med info Prescriber restrictions Coverage duration Criteria will be applied consistent with current AASLD/IDSA guidance Criteria will be applied consistent with current AASLD/IDSA guidance Sprycel Required med info Prescriber restrictions Prescribed by oncologist 68 of 88
69 Stelara Exclusion criteria Crohn's disease Required med info Requires verification that the patient has been evaluated for TB and has been treated accordingly. Prescriber restrictions For Crohn's, coverage is provided when the member has tried and failed Humira unless contraindicated or not tolerated due to documented clinical side effects. All other indications for use require the member has tried and failed Humira and Enbrel, except if contraindicated or not tolerated due to documented clinical side effects. Strensiq Required med info Prescriber restrictions 69 of 88
70 Sutent Required med info Prescriber restrictions Prescribed by oncologist Sylatron Required med info Prescriber restrictions Prescribed by oncologist 70 of 88
71 Sylvant Required med info Prescriber restrictions Tabloid Required med info Prescriber restrictions Prescribed by oncologist or hematologist 71 of 88
72 Tafinlar Required med info Confirmation of the presence of BRAF V600E or BRAF V600K mutation in tumor specimen as detected by an FDA approved test Prescriber restrictions Tagrisso Required med info Prescriber restrictions Coverage duration Lifetime 72 of 88
73 Tarceva Required med info Prescriber restrictions Prescribed by oncologist Targretin/Bexarotene Required med info Prescriber restrictions Prescribed by oncologist or dermatologist 73 of 88
74 Tasigna Required med info Prescriber restrictions Ticfidera Required med info Prescriber restrictions Coverage duration Lifetime 74 of 88
75 Tecentriq Required med info Prescriber restrictions Tetrabenazine Exclusion criteria Coverage for Xenazine or Tetrabenazine will not be provided for patients who have hepatic function impairment, patients who are actively suicidal or who have untreated or inadequately treated depression, or patients taking monoamine oxidase inhibitors or reserpine. Required med info Prescriber restrictions Coverage duration Lifetime 75 of 88
76 Thalomid Required med info Prescriber restrictions Treanda Required med info Prescriber restrictions 76 of 88
77 Tysabri Required med info Prescriber restrictions Coverage is provided for relapsing remitting form of multiple sclerosis when there is documentation of a trial of Copaxone and at least one other interferon beta product unless contraindicated. For Crohns disease coverage is provided with documentation of a trial and failure of Humira and either Cimzia or Stelara Uptravi Required med info Prescriber restrictions 77 of 88
78 Vecamyl Required med info Prescriber restrictions Vectibex Required med info Prescriber restrictions Prescribed by an oncologist 78 of 88
79 Vemlidy Effective Date: April 1, 2018 Required med info Prescriber restrictions Venclexta Required med info Prescriber restrictions Verzenio 79 of 88
80 Effective Date: March 1, 2018 Required med info Prescriber restrictions Vosevi Effective Date: March 1, 2018 Required med info Prescriber restrictions Coverage duration CRITERIA WILL BE APPLIED CONSISTENT WITH CURRENT AASLD/IDSA GUIDANCE. Votrient 80 of 88
81 Required med info Documentation of advanced renal cell carcinoma Prescriber restrictions Prescribed by an oncologist Xalkori Required med info Diagnosis of locally advanced or metastatic non small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (alk) positive as detected by a FDA approved test. Prescriber restrictions 81 of 88
82 Xeljanz Required med info Requires documentation of diagnosis and medication history or intolerance(s). Prescriber restrictions Prescribed or recommended by a rheumatologist Requires a treatment failure or contraindication to Enbrel and Humira. Xgeva Required med info Prescriber restrictions 82 of 88
83 Xolair Required med info Prescriber restrictions Xtandi Required med info Coverage is provided for the treatment of metastatic castration resistant prostate cancer where the patient has had prior treatment with docetaxel. Prescriber restrictions Prescribed or recommended by an oncologist or urologist 83 of 88
84 Xyrem Required med info Prescriber restrictions Yervoy Required med info Prescriber restrictions Prescribed by an oncologist Yondelis 84 of 88
85 Required med info Prescriber restrictions Coverage duration Lifetime Zejula Required med info Prescriber restrictions Coverage duration Lifetime Zelboraf 85 of 88
86 Exclusion criteria Will not be covered in combination with Yervoy Required med info Prescriber restrictions Prescribed by an oncologist Zolinza Required med info Prescriber restrictions Zurampic 86 of 88
87 Required med info Prescriber restrictions Zydelig Required med info Prescriber restrictions Zykadia 87 of 88
88 Required med info Prescriber restrictions Coverage duration Lifetime Zytiga Required med info Prescriber restrictions 88 of 88
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
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
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
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
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
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,
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
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
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
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
ANDROID. Products Affected ANDROID. Prior Authorization Criteria HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016
Prior Authorization HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016 ANDROID ANDROID Supporting statement of diagnosis from the physician. Other 1 BLINCYTO BLINCYTO Known hypersensitivity to blinatumomab
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene topical cream adapalene topical gel Avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT Adagen Age Other 2 ADCIRCA_NVT 2017 Adcirca Diagnosis confirmed by
LIMITED DISTRIBUTION MEDICATIONS
ACTEMRA IV (USSC can dispense 162 mg PFS) ACTHAR HP ACTIMMUNE ADAGEN ADCETRIS CVS Specialty 1-800-237-2767 1-800-237-2767 ADEMPAS ADVATE ALDURAZYME ALECENSA ALIQOPA ALUNBRIG AMPYRA APOKYN ARALAST NP ARCALYST
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
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 mg Glassia Prolastin-C intravenous recon soln Zemaira Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
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
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,
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene 0.3% gel pump adapalene topical cream adapalene topical gel avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT ADAGEN Age Other 2 ADCIRCA_NVT 2017 ADCIRCA
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
ACTHAR HP GEL PA MEDICATION(S) H.P. ACTHAR. COVERED USES All FDA-approved indications not otherwise excluded from Part D. EXCLUSION CRITERIA N/A
ACTHAR HP GEL PA H.P. ACTHAR Criteria for approval are ALL of the following: 1. ONE of: A. Diagnosis of infantile spasm OR B. Diagnosis of multiple sclerosis AND i. Patient is experiencing an acute exacerbation
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases
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ARISTADA Aristada Prefilled Syringe 1064 MG/3.9ML Intramuscular Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular Aristada Prefilled Syringe 882
AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia. Prior Authorization Criteria Health Alliance Plan_2016_HAPFB Updated: 10/2016
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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
ACTEMRA. Products Affected ACTEMRA. Covered Uses All FDA-approved indications not otherwise excluded from Part D. N/A. Exclusion Criteria
ACTEMRA ACTEMRA New starts: Patient has a diagnosis of moderate to severe rheumatoid arthritis (IV or subcutaneous dosage form) and has had a failure, contraindication, or intolerance to two of the following:
Ally Rx D-SNP Current as of r 1, 2017
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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
Pharmacy and Medical Guideline Updates
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AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira
AAT DEFICIENCY Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira PA Details Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI
Somavert ALL FDA-APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.
ACROMEGALY THERAPY Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml Somavert Age Other ALL FDA-APPROVED INDICATIONS NOT OTHERWISE PATIENT PROGRESS NOTES, DOCUMENTATION OF
2015 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS ACTHAR HP GEL... 8 ADCIRCA... 9 AFINITOR AFINITOR DISPERZ AMITIZA...
2015 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS ACTHAR HP GEL... 8 ADCIRCA... 9 AFINITOR... 77 AFINITOR DISPERZ... 77 AMITIZA... 10 amitriptyline... 48 AMPYRA... 11 ANADROL-50... 14 RODERM... 17 ROGEL...
Medical Policy An independent licensee of the Blue Cross Blue Shield Association
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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
ORAL ONCOLOGY CRITERIA
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DIFICID. Products Affected Step 2: DIFICID TABLET 200 MG ORAL. Details
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Pharmacy Management Drug Policy
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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
Exclusion Reasons Presumption of Long- Term Non-Acute Administration C9399 Unclassified Drugs or
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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
ORAL ONCOLOGY CRITERIA
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Clinical Policy: Natalizumab (Tysabri) Reference Number: ERX.SPA.162 Effective Date:
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Please call the Customer Service number on the back of your BCBSM ID card if you have questions about your drug coverage or a drug claim.
Medicare Plus Blue PPO Essential, Vitality, Signature and Assure Plus Comprehensive Formulary Prior Authorization / Step Therapy Program 2017 Plan Year (Updated ) BCBSM Medicare Plus Blue PPO Essential,
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,
CARE N CARE HEALTH PLAN
PPI DEXILANT CAPSULE DELAYED RELEASE 30 MG ORAL DEXILANT CAPSULE DELAYED RELEASE 60 MG ORAL Claim will pay automatically for Dexilant if enrollee has a paid claim for at least a 1 days supply of lansoprazole,
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) Prior Authorization Requirements
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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
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.
2018 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA
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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 Subject: Cimzia Page: 1 of 5 Last Review Date: December 8, 2017 Cimzia Description Cimzia (certolizumab
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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 6 Last Review Date: September 15, 2016 Simponi / Simponi
Cimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Cimzia Page: 1 of 5 Last Review Date: March 17, 2017 Cimzia Description Cimzia (certolizumab pegol)
ACTEMRA. Cigna Medicare Rx (PDP) 2014 Cigna Medicare Rx Secure-Xtra Plan (PDP) Formulary. Products Affected Actemra. Prior Authorization Criteria
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Please call the Customer Service number on the back of your BCBSM ID card if you have questions about your drug coverage or a drug claim.
Medicare Plus Blue Group PPO Essential, Vitality, Signature and Assure, Medicare Plus Group PPO, and Prescription Blue Group PDP Plus Comprehensive Formulary Prior Authorization / Step Therapy Program
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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
3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Renflexis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
ARISTADA. Products Affected Step 2: ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.
ARISTADA ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 662 MG/2.4ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 882
2018 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS
2018 PRIOR AUTHORIZATION CRITERIA TABLE OF CONTENTS ADASUVE...25 ADCIRCA...12 ADEMPAS...14 AFINITOR... 140 AFINITOR DISPERZ... 140 ALECENSA... 140 ALUNBRIG... 140 amabelz tablet...90 AMITIZA...17 amitriptyline
All medically accepted Prior authorization applies to new starts only excluded from Part D. 12 months
2018 Cigna-HealthSpring Prior Authorization Criteria Drug Name Excluded Prior Authorization Product Age Prescriber Coverage Covered Uses Exclusion Criteria Required Medical Information Other Criteria Drug
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
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
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:
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
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
2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
Regulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of:
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 8 Last Review Date: March 17, 2017 Simponi / Simponi
Prior Authorization Drug List
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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
2018 Prior Authorization (PA) Criteria
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2018 Cigna-HealthSpring Prior Authorization Criteria
2018 Cigna-HealthSpring Prior Authorization Criteria Drug Name Prior Authorization Type Description Product Group Covered Uses Exclusion Criteria Required Medical Information Age Restrictions Prescriber
2. Is the patient responding to Remicade therapy? Y N
09/29/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Remicade (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
2019 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA
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2019 Prior Authorization
2019 Prior Authorization FID 19148 Prior Authorization ACTEMRA Products Affected Actemra INJ 162MG/0.9ML PA Details Age Other 1 ACTIMMUNE Products Affected Actimmune PA Details Age Other 2 ADEMPAS Products
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 6 Last Review Date: December 8, 2017 Orencia Description Orencia (abatacept)
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
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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
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
Biologics for Autoimmune Diseases
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First Name. Specialty: Fax. First Name DOB: Duration:
Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis: