Brand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit

Transcription

1 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 Request Form (please fax request to ) Brand Generic J-Code 1 Billable Unit Covered Uses Botox Onabotulinumtoxin A J unit Primary axillary hyperhidrosis in adults Blepharospasm (>12 years old) Strabismus (>12 years old) Cervical Dystonia (>16 years old) Hemifacial Spasm Upper extremity spasticity Overactive bladder Neurogenic bladder Chronic migraine Spasticity related to Cerebral Palsy Achalasia Required Medical Information and Criteria Neurologic workup Trial of at least 3 classes of migraine Hyperhidrosis disease severity scale (HDSS) score Myobloc Rimabotulinumtoxin B J units Cervical Dystonia Neurologic workup with previous methods tried Dysport Abobotulinumtoxin A J units Xeomin Incobotulinumtoxin A J unit Blepharospasm Cervical Dystonia Cinryze J0598 Hereditary angioedema C1 esterase inhibitor (human) 10 units (HAE) (>12 years old) Berinert J0597 Previous medication trials Confirmed diagnosis of HAE by laboratory testing (Last Revised 5/2013) Exclusion Criteria Cosmetics uses Lower limb spasticity Diabetic neuropathic pain Emergency CABG

2 Firazyr Icatibant J1744 Kalbitor Ecallantide J mg Acute attacks of HAE Laboratory confirmation of HAE Administered by appropriate health care specialist Caverject Alprostadil J mcg Diagnosis of Erectile Dysfunction (ED) Muse Aplrostadil urethral J mcg Complete physical examination. Treatment of ED Registered Sex Offender Male infertility Pavacot Papaverine J mg Oraverse Phentolamine J mg Lupron Depot Lupron Leuprolide J1950 J mg 7.5 mg Central Precocious Puberty (CPP) Endometriosis Uterine leiomyomata with anemia Prostate Cancer (PC) Breast Cancer (BC) Ovarian Cancer Laboratory confirmation PC: PSA, Gleason score. BC: hormone receptor (+), CPP: GnRH test, bone age assessment, imaging of the brain, age. Delayed puberty for short stature Vantas Histrelin Implant J mg Prostate Cancer (PC) Laboratory confirmation PSA, Gleason Score. Disease staging

3 Supprelin LA Histrelin Implant J mg Central Precocious Puberty Laboratory confirmation GnRH test, bone age assessment, imaging of the brain, age. Age < 2 Delayed puberty Makena Hydroxyprogesterone Caproate J mg Reduce the risk of preterm birth in women, with a singleton pregnancy, who has a history of singleton spontaneous preterm birth. Xolair Omalizumab J mg Moderate to severe persistent asthma (+) skin test reactive to perennial aeroallergen Inadequately controlled by corticosteroids. Synagis (Seasonal usage November-March) Palivizumab mg Prevention of lower respiratory tract disease in infants at high risk for RSV o Chronic Lung Previous history of singleton pregnancy Previous history of spontaneous preterm birth. Compounded hydroxyprogester one preferred (No Authorization required) Provider can contact Alere directly at or fax Age > 12 y/o IgE level Body Weight Previous use/adherence to inhaled steroids and Long Acting Beta Agonist Gestational age Actual age < 24 months Short cervix Current or planned cerclage Allergy to peanuts Allergic rhinitis Latex Allergy Dosing outside manufacturer s recommendations according to body weight and IgE levels Hypersensitivity Cystic Fibrosis

4 Cytogam J ml Privigen J mg J ml Immune Globulin Disease o Premature Infant o Congenital Abnormality of airway/neuromuscu lar Condition o Hemodynamically unstable chronic heart disease Primary Immune Deficiency: Congenital Agammaglobulinemia Hypogammaglobulinemia levels should be while patient is free from infection to pneumococcus, tetanus, and/or diphtheria Fibromyalgia Lyme Disease Pediatric Epilepsy Neuropathy Gammaplex J mg infections -Authorizations trough IgG levels; documenting patient response to Ig. Hizentra J mg Bone Marrow Gammaked J mg Transplant: Bone Marrow Transplant Transplant Date of transplant, detailed patient history Gamunex Immune Globulin J mg Kawasaki CBC Vivaglobin J mg Serum ESR Serum C-reactive protein Serum LFTs Gammagard liquid J mg

5 Octagam J mg Hyperrho S/D J mcg/ 250 IU Carimune J mg Flebogamma J mg Secondary Immunodeficiency: Chronic Lymphocytic Leukemia with Hypogammaglobulinemia (CLL) B cell CLL Hematology: Idiopathic Thrombocytopenia Purpura (ITP) Prophylaxis of rubella during pregnancy Prophylaxis of hepatitis A Post-exposure varicella Total IgG levels Laboratory values used to confirm diagnosis Neurological Conditions: Chronic Inflammatory Demyelinating Polyneuropathy (CIPD) Inflammatory Myopathies (Polymyositis, Dermatomyositis) Guillain-Barre Syndrome Myasthenia Gravis exacerbation Multifocal Motor Neuropathy Relapsing/Remitting Multiple Sclerosis Testing used to confirm diagnosis (examples: EMG, Nerve Conduction Study (NCS), muscle biopsy, MRI, CSF protein, Anti-Mag antibodies, Anti-GD1a, Anti-GD1b) Documentation of standard treatment tried/failed/contraindicat e Multifocal Motor Neuropathy Anti-GM 1 antibody results Miscellaneous Codes Unclassified Meds J3490 Requires review with clinical documentation

6 J3590 It is the policy of Affinity Health Plan to require prior authorization for medical claims for the following drugs when administered in an office or clinic setting: In addition, all drugs requested by nonparticipating providers shall require prior authorization i.e. Specialty Pharmacies. All drugs that are self-administered are covered as part of the Pharmacy Benefit. Prior authorization will be required in order to be covered as a Medical Benefit. Any drug that does not have the indication supported by FDA or Compendia requires authorization. Acceptable Compendia are Micromedex DrugDex and NCCN (National Comprehensive Cancer Network).