STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
|
|
- Lauren Kelley
- 5 years ago
- Views:
Transcription
1 STAT Bulletin November 28, 2011 Volume 9: Issue 27 To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat The attached Drug Therapy Guidelines are effective January 1, These updates are a result of the annual guideline review and new drug evaluations performed quarterly by our Pharmacy and Therapeutics Committee, or as a result of new medications entering the market. What you need to know The updated Drug Therapy Guidelines will be available for review online as of December 1, 2011 at healthnowny.com. Select Providers > Clinical Resources > Pharmacy Services. What you need to do If you do not have access to the internet, paper copies are available, upon request, as of December 1, by calling Provider Service at: : Option 1, 1, 1 (Syracuse area) Option 2 (for Cornell University members) Option 3, 2 (Rochester area) : Option 3 (mid-hudson area) 5768 HNNY CC
2 Prescription Drug/Policy Sylatron Non-Formulary ication Coverage Exceptions Adcetris New Guidelines Policy Summary (See guidelines for all specifics) Covered for FDA-approved indication of melanoma with microscopic or gross nodal involvement within 84 days of definitive surgical resection including complete lymphadenectomy (full Sylatron policy found in the Drug Therapy Guidelines: Abbreviated Criteria document on our website) Considerations used to determine coverage when requests for non-formulary medications are submitted are outlined in this policy Covered for FDA-approved indication (per the Global Authorization Criteria) or Actemra Drug Therapy Guideline Title Actimmune Amevive Guidelines with changes that will impact the review process Policy Criteria Changes Summary (See guidelines for specifics) Dosage information added with regards to ANC, plts, and AST/ALT Lab values required for renewal are more lenient Specialist criteria added to the policy Hematologist, immunologist, infectious disease specialist for chronic granulomatous disease Endocrinologist for osteopetrosis Addition of diagnostic criteria Addition of specific requirements for other therapies (topical, oral, biologic, photo) first (including both Enbrel and Humira) Addition of specialist requirements Addition of age requirements 2 or Ampyra No changes Antinarcoleptic Agents Specialist notes/polysomnography required for narcolepsy diagnosis if not requested by a neurologist or pulmonologist Coverage duration for narcolepsy increased to 2 years Apokyn Policy abolished Benign Prostatic Hyperplasia (BPH) Therapy No changes
3 Drug Therapy Guideline Title Botulinum Toxins Policy Criteria Changes Summary (See guidelines for specifics) Changed wording from chronic daily headache to wording as found in the Botox Prescribing Information Indication Included specific examples of first line therapies for hyperhidrosis Coverage for the treatment of plantar hyperhidrosis considered investigational and not covered Coverage for sialorrhea available when associated with neurological disorders Policy exclusion list limited Criteria added for coverage in piriformis syndrome Renewal criteria specified as same as initial criteria 3 or Colony Stimulating Factors Enbrel No changes Erectile Dysfunction Coverage duration increased Agents Daily dosing covered for Cialis 2.5mg and 5mg tablets Forteo Requirement of diagnostic DXA scan and/or FRAX score added Gonadotropin-Releasing Hormone Agonist Requirement of iron usage timeframes added for anemia secondary to uterine leiomyomata Quantity allowances and coverage duration revised Removal of diagnosis from autopay, will now be reviewed Central precocious puberty (259.1) no longer autopay diagnosis, will be reviewed o Coverage criteria outlined based on age o Renewal criteria outlined based on age Clarification of pharmacy benefit vs. medical benefit made Coverage criteria for breast and ovarian cancers included Humira No changes Idiopathic / Thrombocytopenia Purpura (ITP) Agents No changes Incretin Mimetics Trial with Byetta no longer required for coverage of Victoza Injectable Fertility No changes ications Inspra Policy abolished Approval duration extended Intranasal Steroids Triamcinolone added as preferred agent Nasarel, Nasacort AQ removed from policy Iressa Recommendation to abolish policy based on lack of
4 Drug Therapy Guideline Title Policy Criteria Changes Summary (See guidelines for specifics) inappropriate and low use or Leukotriene Receptor Antagonists Approval duration extended Nutritional Supplements No changes Orencia Addition of Orencia SC to the policy / Proton Pump Inhibitors (PPIs) Pulmonary Arterial Hypertension (PAH) Agents Coverage of non-preferred PPIs require trial with preferred agents at maximum dosing (i.e. twice daily) with failure to provide benefit Addition of Veletri to policy Removal of Black Box warning from Letairis Implement prior authorization reviews of Ventavis, Flolan, and Veletri Clarification of pharmacy vs. medical benefit made / RANKL Inhibitors Addition of diagnostic criteria for osteoporosis Sedative Hypnotics No changes Selective Serotonin Reuptake Inhibitors Requirement of trial with at least two generic SSRIs first This represents a change from old policy for Lexapro, which required two generic SSRIs, one of which must have been citalopram Based on indication of and new safety concerns with citalopram, policy changed to allow for any two generics Addition of GIST coverage Gleevec trial required prior to coverage for CML Sprycel accelerated or blast crisis phase Requirement of Ph+ or BCR/ABL+ verification for first line use in CML in chronic phase Coverage criteria added for pancreatic neuroendocrine Sutent tumor treatment, soft tissue sarcoma treatment, and thyroid carcinoma treatment Tasigna Specific criteria outlined for each phase of CML Testosterone Replacements Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Approval duration extended Initial coverage duration for Voltaren Gel and Pennsaid extended Urinary Agents Approval duration extended 4
5 Auto-Pay ICD-9 Codes for Selected ical ications Some medical benefit medications will automatically pay when billed with the following diagnoses as listed below: ication (J code) Auto-pay ICD-9 codes Arzerra (J9302) 204.1, , , Avastin (J9035, C9257) Rituxan (J9310) , , , , , , , , , ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), ( ), Lupron, Lupron Depot, Eligard (J1950, J9217, J9218) 185 IVIg (J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1599) 446.1, Dacogen, Vidaza (J0894, J9025) 205.1, , , , Botox, Myobloc, Dysport, Xeomin (J0585, J0586, J0587, J0588) 333.6, 333.7, , , , , , , 334.1, 340, 341, 341.0, 341.1, 341.2, , 341.8, 341.9, 342.1, , 343, , 344.0, , 344.1, 344.2, 344.4, , 351.8, 378, , , , 530.0, 564.6, 565.0, 723.5, 854, 854.0, 854.1, , 952, ,
6 ical Reference Guide The following list of medications require preauthorization when administered by a health care professional. Drug Code Actemra J3262 Actimmune J9216 *Adcetris - non-institutional use J9999 *Adcetris - institutional use C9287 Amevive J0215 Arzerra J9302 Avastin C9257 Avastin J9035 Benlysta J0490 Berinert J0597 Boniva J1740 Botox J0585 Cimzia J0718 Cinryze J0598 Dacogen J0894 Dysport J0586 Eligard J9217 Erbitux J9055 Flebogamma J1572 *Flolan J1325 Gammagard J1569 Gammaplex J1557 Gamunex J1561 Gamunex-C J1561 H.P. Acthar Gel J0800 Halaven J9179 Herceptin J9355 Hizentra J1559 Istodax J9315 IVIg (NOS) J1599 IVIg Powder J1566 Jevtana J9043 Kalbitor J1290 Krystexxa J2507 Drug Code Lucentis J2778 Lupron Depot J1950 Lupron J9218 Macugen J2503 Makena J1725 Mozobil J2562 Myobloc J0587 Nplate J2796 Octagam J1568 Orencia J0129 Privigen J1459 ProliaTM J0897 Provenge Q2043 Qutenza J7335 Reclast J3488 Remicade J1745 Remodulin J3285 Rituxan J9310 Simponi J3590 Soliris J1300 Stelara J3357 Synagis Torisel J9330 Tysabri J2323 Vectibix J9303 *Veletri J1325 *Ventavis Q4074 Vidaza J9025 Vivaglobin J1562 Xeomin J0588 Xgeva J0897 Xolair J2357 Yervoy J9228 *New as of January 1,
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
STAT Bulletin November 28, 2011 Volume 17: Issue 34 To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat
More informationPharmacy and Medical Guideline Updates
STAT Bulletin PO Box 15013 Albany, New York 12212 August 2, 2010 Volume 8: Issue 19 To: All PCPs and Specialists Contracts Affected: All Lines of Business Pharmacy and ical Guideline Updates As a result
More informationSPECIALTY PHARMACY Master Clinical Drug List
Abraxane J9264 Provider ONCOLOGY None NO Actemra J3262 Provider ARTHRITIS PA - all YES Acthar HP Gel J0800 Prov/Self Med/Pharm ENDOCRINE/METABOLIC PA - all YES Adagen J2504 Provider ENZYME DISORDERS None
More informationDrug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
More informationMedStar Medicare Choice Pharmacy Services
Pharmacy Services 1 MedStar Medicare Choice Pharmacy Services Table of Contents At a Glance..page 2 Pharmacy Policies..page 4 Medicare Choice Pharmacy Programs..page 6 Where to Obtain Prescriptions..page
More informationPrescription 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
More informationProvider Administered Drug Program (PADP) and Physician Administered Drug VPSS List
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
More informationPrescription 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
More informationPRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
More informationBrand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit
Affinity Health Plan Department Of Pharmacy (Medicaid, Child Health Plus, Family Health Plus, Medicare Part B) **Medications Requiring Authorization under Medical Benefit** Click Here For Medication Authorization
More informationPharmacy Services Request Types
FOR DRUG REQUESTS, ONLY-- * NOTE: Only those drugs administered by a healthcare provider and billed medically would be entered via CareAffiliate. * Oral drugs would not be administered by a healthcare
More informationBCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015
Prior Authorization List 2015 Participating providers are responsible to furnish or arrange health care services with other participating healthcare facilities or providers. Prior authorization requests
More informationPRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
More informationPA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116
More informationInjectable Drugs Requiring Pre-Service Approval
Abatacept Orencia J0129, 10 mg 1500 FL LCD- L29051 1) For patients with rheumatoid arthritis with failure, intolerance or contraindications to methotrexate. Limit dosing to 40 mg Q 2 weeks. 2) For patients
More informationMETABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ALPHA-1 PROTEINASE INHIBITORS ARANESP BLOOD CELL DEFICIENCY ARANESP ARCALYST
PRIOR AUTHORIZATION LIST (SUBJECT TO CHANGE) MEDICATION THERAPEUTIC CATEGORY MODULE ACTEMRA INFLAMMATORY CONDITIONS ACTEMRA ADCIRCA PULMONARY HYPERTENSION PDE-5 INHIBITORS FOR PAH ADDYI SEXUAL DISORDERS
More informationMedical Prior Authorization List Rosen Employee Plans For prescription drug requirements, contact EHIM toll-free at
For prescription drug requirements, contact EHIM toll-free at 1.800.311.3446. General Information These requirements are administered by Health First Health Plans ( Health Plan ). Benefits are determined
More informationNew Billing Guidelines for Home Infusion, Enteral and Parenteral Therapies Home Infusion Fee Schedule Effective July 1, 2009
STAT Bulletin PO Box 80 Buffalo, New York 14240-0080 May 12, 2009 Volume 15:Issue 18 To: All Home Health Care and Home Infusion Therapy Providers Contracts Effected: All Lines of Business New Billing Guidelines
More informationAetna Better Health. Specialty Drug Program
Aetna Better Health is managed through CVS Health Specialty Pharmacy. The Specialty pharmacies fill prescriptions and ship drugs for complex medical conditions, including multiple sclerosis, rheumatoid
More informationClinical Policy: Eltrombopag (Promacta) Reference Number: ERX.SPA.71 Effective Date:
Clinical Policy: (Promacta) Reference Number: ERX.SPA.71 Effective Date: 10.01.16 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More information2016 MDwise HIP Medical Services that Require Prior Authorization
2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
More informationINJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions
J9190 5-FU fluorouracil None. J0401 ABILIFY MAINTENA aripiprazole i.v. J9264 ABRAXANE paclitaxel protein bound J3262 ACTEMRA IV tocilizumab Yes, through Navitus. Restricted to (in at least consultation
More informationPHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017
PHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017 A meeting of the Health Partners Pharmacy and Therapeutics (P&T) Committee was held on September and December 2017. The following are the recommendations
More informationPA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131
More information* Note: please reference the Highmark Health Options Gender Transition Services (MP- 033-MD-DE) policy for all gender dysphoria requests.
Request for Prior Authorization for Lupron, Lupron Depot (leuprolide acetate) Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Lupron (leuprolide acetate)
More informationHMSA Pharmacy Newsletter April 2006 For Participating Medical Practitioners
For Participating Medical Practitioners CDC HEALTH ALERT - USE OF ANTIVIRALS FOR INFLUENZA The U.S. Centers for Disease Control and Prevention (CDC) issued a Health Alert on January 14, 2006 regarding
More informationMDwise Hoosier Care Connect Medical Services that Require Prior Authorization
MDwise Hoosier Care Connect Medical Services that Require Prior Authorization Certain Indiana Health Coverage Programs (IHCP) services require prior authorization (PA) for members enrolled in the Hoosier
More information1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Eligard Trelstar - Vantas (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationKentucky Department for Medicaid Services. Drug Review Options
Kentucky Department for Medicaid Services Drug Review Options The following chart lists the agenda items scheduled and the options submitted for review at the March 18, 2010 meeting of the Pharmacy and
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Promacta) Reference Number: CP.PHAR.180 Effective Date: 03.01.16 Last Review Date: 02.18 Line of Business: Commercial, Health Insurance Marketplace, Medicaid Revision Log See Important
More informationModular Program Report
Modular Program Report The following report(s) provides findings from an FDA initiated query using its Mini Sentinel pilot. While Mini Sentinel queries may be undertaken to assess potential medical product
More informationOriginal Policy Date
MP 5.01.17 Specialty Drugs Medical Policy Section Prescription Drug Issue 12:2013 Original Policy Date 12:2013 Last Review Status/ Date Local policy Last updated/12:2013 Return to Medical Policy Index
More informationStep Therapy Criteria
ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member
More information2016 MDwise HIP Medical Services that Require Prior Authorization
2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Coding All Out of Network services Facility to facility ambulance transport
More informationORILISSA (elagolix) oral tablet
ORILISSA (elagolix) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationPremera Blue Cross Medicare Advantage Plans Medical Policy Updates
Premera Blue Cross Medicare Advantage Plans Medical Policy Updates Medical Policy and Criteria Premera Blue Cross Medicare Advantage reviews all medical policies and criteria annually. The following updates
More informationHMSA Pharmacy Newsletter February
HMSA s HMSA Pharmacy Newsletter February 2006 www.hmsa.com/portal/provider CDC HEALTH ALERT - USE OF ANTIVIRALS FOR INFLUENZA The U.S. Centers for Disease Control and Prevention (CDC) issued a Health Alert
More informationSpecialty 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
More informationHEALTHTEAM 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,
More informationBRINTELLIX. Step Therapy Criteria HealthTeam Advantage Formulary ID: Version 6 Effective Date: 1/1/2016. PRODUCT(s) AFFECTED BRINTELLIX
BRINTELLIX BRINTELLIX Claim will pay automatically for brintellix if enrollee has a paid claim for at least a 1 days supply of any 2 generic formulary antidepressants in the past 365 days. Otherwise, brintellix
More informationHEALTHTEAM 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
More informationXeljanz. 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 5 Last Review Date: March 18, 2016 Xeljanz Description Xeljanz, Xeljanz
More informationIHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT NOVEMBER 30, 2010
IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT201056 NOVEMBER 30, 2010 Changes to the Preferred Drug List Changes to the Preferred Drug List (PDL) were made at the November 19, 2010, Drug Utilization
More informationCARE 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,
More informationPulmonary 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
More informationERLEADA (apalutamide) oral tablet
ERLEADA (apalutamide) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Sprycel) Reference Number: CP.PHAR.72 Effective Date: 07.01.18 Last Review Date: 05.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end of this policy
More informationXeljanz. 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 5 Last Review Date: March 17, 2017 Xeljanz Description Xeljanz, Xeljanz
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization AETA BETTER HEALTH MICHIGA Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationRationale for Decision Excluded Generic OTC equivalent available (Flonase Allergy Relief) Medicare status (if differs)
BLUE SHIELD OF CALIFORNIA FIRST QUARTER 2015 FORMULARY AND MEDICATION POLICY UPDATES EFFECTIVE MARCH 19, 2015 The Blue Shield of California (BSC) Pharmacy and Therapeutics (P&T) Committee, consisting of
More informationHEALTHTEAM ADVANTAGE PLAN 2017 Step Therapy Criteria Pending CMS Approval
ARISTADA - ARISTADA INJ 441MG/1.6 ARISTADA INJ 662MG/2.4 ARISTADA INJ 882MG/3.2 CLAIM WILL PAY AUTOMATICALLY FOR ARISTADA IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ABILIFY MAINTENA AND
More informationProvider Newsletter. Table of Contents. Reimbursement Policy: Improve member medication regimen. Page 2
Provider Newsletter https://providers.amerigroup.com/ April 2018 Table of Contents Improve member medication regimen Page 2 Medical Policies and Clinical Utilization Management Guidelines updated Page
More information2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
More informationContents Please refer to Medical Policy I-40 Pertuzumab (Perjeta) for additional information.
May 2018 In This Issue Coverage Guidelines Revised for Azacitidine (Vidaza)... 3 Coverage Guidelines Revised for Fulvestrant (Faslodex)... 4 Place of Service Revised for Total Hip and Total Knee Arthroplasty...
More information2017 MDwise HIP Medical Services that Require Prior Authorization
2017 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
More informationLIMITED 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
More informationDIFICID. Products Affected Step 2: DIFICID TABLET 200 MG ORAL. Details
DIFICID DIFICID TABLET 200 MG ORAL Claim will pay automatically for Dificid if enrollee has a paid claim for at least a 1 days supply of vancomycin in the past. Otherwise, Dificid requires a step therapy
More informationBosulif. Bosulif (bosutinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.22 Section: Prescription Drugs Effective Date: April 1,2018 Subject: Bosulif Page: 1 of 5 Last Review
More informationDrug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy
More informationPrior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD
Abatacept (Orencia) 1, 2, 7, 11, 13, 14, 18, 24, 31, 44, 48, 49, 51, 53, 55, 57 J0129 Alpha 1 - Proteinase inhibitor (Prolastin-C) 5, 6, 10, 12, 40 Medically Necessary (if all the following criteria apply):
More informationDrug Class Prior Authorization Criteria Immune Globulins
Drug Class Prior Authorization Criteria Immune Globulins Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy has been developed through review of
More informationP.E.I. Drug Programs. Formulary Update. Issue June 09, 2010
P.E.I. Drug Programs Formulary Update Issue 10-01 June 09, 2010 st Effective July 1, 2010, the following medications will be added to the P.E.I. Drug Formulary. New medications for the treatment of ankylosing
More informationActemra. Products Affected ACTEMRA INTRAVENOUS. Covered Uses
Actemra ACTEMRA INTRAVENOUS All medically accepted indications not otherwise excluded plus patients already started on tocilizumab for a covered use. Castleman's disease. Still's disease. Concurrent use
More informationCARE N CARE HEALTH PLAN
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
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Immunoglobulin for Parvovirus B19 Infection Reference Number: CP.CPA.90 Effective Date: 11.16.16 Last Review Date: 08.17 Line of Business: Commercial Revision Log See Important Reminder
More informationActemra. Products Affected ACTEMRA INTRAVENOUS. Covered Uses
Actemra ACTEMRA INTRAVENOUS All medically accepted indications not otherwise excluded plus patients already started on tocilizumab for a covered use. Castleman's disease. Still's disease. Concurrent use
More informationRegulatory 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)
More information2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
More informationJ-Code Trade Name Drug Name Required Medical Information
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES Updated: 10/31/2017 J-Code Prior Authorizations & Required Clinical Information Medicaid, Child Health Plus, HealthierLife, Metal-Level J-Code Trade
More informationCHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER
RAND WATER MEDICAL SCHEME RAND WATER MEDICAL SCHEME CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER LIST OF CHRONIC CONDITIONS Conditions covered under s chronic medication benefit are detailed below.
More informationPharmacy 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
More informationCARE N CARE HEALTH PLAN
ARISTADA Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular Aristada Prefilled Syringe 882 MG/3.2ML Intramuscular Claim will pay automatically for
More informationDrug 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
More informationSpecialty Overview by Prior Authorization Approval or Denial 4th Quarter 2016
Specialty Overview by Prior Authorization Approval or 4th Quarter 2016 Carrier Physician Specialty Drug Drug Class Decision Comments Reporting Year Reporting Month 3961 GASTROENTEROLOGY Humira RHEUMATOID
More informationPercent Brand Name Generic Name Strength How Supplied NDC from AWP/SWP Adcetris. Amprya dalfampridine 10 mg 60 count bottle
Department of General Services Procurement Division Contract # 01-14- 65-57 Pharmaceutical Acquisitions Section Exhibit G-1 April 30, 2015 Walgreens Specialty Pharmacy LLC, Products Pricing Crescent Healthcare,
More informationReferral Forms for TYVASO and REMODULIN
Referral Forms for TYVASO and REMODULIN HOW TO GET STARTED Tyvaso and Remodulin are available only through select Specialty Pharmacy Services (SPS) providers. Follow these 5 simple steps to complete each
More informationList of Designated High-Cost Drugs
List of Designated High-Cost Drugs UPDATED APRIL 25, 2018 For details on the High-Cost Drug policy, see Section 5.8 of the PharmaCare Policy Manual. Recent updates appear in red. Deletions are listed at
More informationFIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES J Code Prior Authorizations & Required Clinical Information 2011 (Updated 3/14/11)
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES J Code Prior Authorizations & Required Clinical Information 2011 (Updated 3/14/11) Brand Generic J Code Covered Uses Required Medical Information and
More informationPrior Authorization Program
Prescription Drug List January 2011 Prior Authorization Program The prior authorization program helps us offer broad prescription drug coverage and promotes safe, clinically appropriate drug usage. Under
More informationSpecialty conditions overview
Specialty conditions overview Prevalence and cost Click on the vials to learn more about these specialty conditions. 1. Approximate annual AWP cost per patient of top utilized drugs for UHC calendar year
More informationIMMUNE GLOBULIN (IVIG AND SCIG) Brand Name Generic Name Length of Authorization Bivigam IVIG Per Medical Guidelines Carimune IVIG Per Medical
Brand Name Generic Name Length of Authorization Bivigam IVIG Per Medical Guidelines Carimune IVIG Per Medical Guidelines Flebogamma IVIG Per Medical Guidelines Gammagard IVIG/SCIG Per Medical Guidelines
More informationRegulatory 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)
More informationTexas Vendor Drug Program. Formulary Drug Index File Layout. Layout effective: Jul. 2, 2018 Document update: Oct. 1, 2018
Texas Vendor Drug Program Formulary Drug Index File Layout Layout effective: Jul. 2, 2018 Document update: Oct. 1, 2018 The Vendor Drug Program provides a weekly update of resource data available for download
More informationOntario Public Drug Programs
Ontario Public Drug Programs Notice from the Executive Officer: Temporary Facilitated Access Mechanism (Rheumatology) for Ontario Drug Benefit Recipients aged 24 years and under December 14, 2017 Effective
More informationPharmacy Management Drug Policy
SUBJECT: POLICY NUMBER: PHARMACY-63 EFFECTIVE DATE: 12/04 LAST REVIEW DATE: 1/29/2018 If the member s subscriber contract excludes coverage for a specific service or prescription drug, it is not covered
More informationMedical Policies and Clinical Utilization Management Guidelines update
Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update Summary: On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following
More information2018 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA
2018 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) These drugs require authorization before dispensing
More information2. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)?
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Botulinum Toxins (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationMEDICAL ASSISTANCE BULLETIN
ISSUE DATE February 18, 2015 SUBJECT EFFECTIVE DATE January 21, 2015 MEDICAL ASSISTANCE BULLETIN NUMBER *See below BY Drug List (PDL) Update January 21, 2015 Pharmacy Services Vincent D. Gordon, Deputy
More information2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Opsumit) Reference Number: CP.CPA.107 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
More informationRHEUMATOID 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
More information2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
More informationCHRONIC MEDICATION PROGRAMME INCLUDES PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL)
CHRONIC MEDICATION PROGRAMME INCLUDES PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL) A. GENERAL INFORMATION LIST OF CHRONIC CONDITIONS Conditions covered under KeyHealth s chronic medication benefit
More informationUtilization Management
Abraxane Abraxane Actemra (IV) Inflammatory Conditions PA/Step Actemra (SQ) Inflammatory Conditions PA/Step Acthar HP Miscellaneous CNS Disorders PA Actimmune NF Adcetris Adcirca Adempas Advate (all forms)
More informationClinical Policy: Nilotinib (Tasigna) Reference Number: CP.CPA.162 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: (Tasigna) Reference Number: CP.CPA.162 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important
More information