Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List

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Transcription:

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 ), 1 mg Effective 04/01/2015 J0256 Injection, alpha 1-proteinase inhibitor, human (Aralast NP, Prolastin, Zemairra ), 10 mg, not otherwise specified J0257 Injection, alpha 1 proteinase inhibitor (human)(glassia ), 10 mg J0585 Injection, onabotulinumtoxina (Botox, Botox Cosmetic), 1 unit J0586 Injection, abobotulinumtoxina (Dysport ), 5 units J0587 Injection, rimabotulinumtoxinb (Myobloc ),100 units J0588 Injection, incobotulinumtoxina (Xeomin ), 1 unit J0597 Injection, C-1 esterase inhibitor (human)(berinert ), 10 units J0641 Injection, levoleucovorin calcium (Fusilev ), 0.5 mg Effective 04/01/2015

J0717 Injection, certolizumab pegol (Cimzia ), 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is selfadministered) J0800 Injection, corticotropin (H.P. Acthar Gel), up to 40 units J0881 Darbepoetin Alfa (Aranesp ), 1 microgram (nonesrd use) Effective 07/20/2009 J0885 Epoetin Alfa (Epogen, Procrit ), (for non-esrd use), 1000 units Effective 07/20/2009 J0897 Injection, denosumab (Prolia, Xgeva ), 1 mg J1290 Injection, ecallantide (Kalbitor ), 1 mg J1300 Injection, eculizumab (Soliris ), 10 mg J1442 Injection, filgrastim (G-CSF) (Neupogen ), 1 microgram Effective 07/20/2009 J1459 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg J1556 Injection, immune globulin (Bivigam), 500 mg J1557 Injection, immune globulin, (Gammaplex) intravenous, nonlyophilized (e.g., liquid), 500 mg J1561 Injection, immune globulin, (Gamunex- C,Gammaked), nonlyophilized (e.g., liquid), 500 mg J1562 Injection, immune globulin (vivaglobin), 100 mg Eff. 01/16/2012 Termed 12/31/2014 J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder) (Carimune NF, Panglobulin NF and Gammagard S/D), not otherwise specified, 500 mg

J1568 Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg J1569 Injection, immune globulin, (Gammagard Liquid), intravenous J1572 Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, nonlyophilized (e.g., liquid), 500 mg J1599 Injection, immune globulin, intravenous. nonlyophilized (e.g., liquid), not otherwise specified, 500 mg J1745 Injection, infliximab (Remicade ), 10 mg J1786 Injection, imiglucerase (Cerezyme ), 10 units J1950 Injection, leuprolide acetate (for depot suspension)(lupron Depot, Lupron Depot-PED ), per 3.75 mg J2323 Injection, natalizumab (Tysabri ), 1 mg J2353 Injection, octreotide (SandoSTATIN LAR), depot form for intramuscular injection, 1 mg J2357 Injection, omalizumab (Xolair ), 5 mg J2469 Palonosetron Hydrochloride (Aloxi ), 25 mcg Effective 07/20/2009 J2503 Injection, pegaptanib sodium (Macugen), 0.3 mg Effective 04/01/2015 J2505 Injection, pegfilgrastim (Neulasta ), 6 mg Effective 07/20/2009 J2778 Injection, ranibizumab (Lucentis ), 0.1 mg Effective 04/01/2015 J2796 Injection, romiplostim (Nplate ), 10 micrograms J3262 Injection, tocilizumab (Actemra ), 1 mg

J3315 Injection, triptorelin pamoate (Trelstar ), 3.75 mg J3357 Injection, ustekinumab (Stelara ), 1 mg J3385 Injection, velaglucerase alfa (VIPRIV ), 100 units J3489 Injection, zoledronic acid (Reclast, Zometa ), 1 mg J3590 NDC: 64764-0300-20 Injection, vedolizumab (Entyvio ), 1 mg Effective 04/01/2015 J7321 Hyaluronan or derivative (Hyalgan or Supartz ) for intra-articular J7323 Hyaluronan or derivative (Euflexxa ) for intraarticular J7324 Hyaluronan or derivative (Orthovisc ) for intraarticular J7325 Hyaluronan or derivative (Synvisc or Synvisc- One ) for intra-articular injection, 1 mg J7326 Hyaluronan or derivative (Gel-One ) for intraarticular J7327 Hyaluronan or derivative (Monovisc), for intraarticular Effective 01/01/2015 J9025 Injection, azacitidine (Vidaza ), 1 mg Effective 04/01/2015 J9033 Injection, bendamustine HCl (Treanda ), 1 mg Effective 04/01/2015 J9035 Injection, bevacizumab (Avastin ), 10 mg Effective 07/20/2009 J9041 Injection, bortezomib (Velcade ), 0.1 mg J9043 Injection, cabazitaxel (Jevtana ), 1 mg

J9055 Injection, cetuximab (Erbitux), 10 mg J9155 Injection, degarelix (Firmagon ), 1 mg Effective 04/1/2013 Terminated 12/31/2014 J9171 Injection, docetaxel (Taxotere, Docefrez ), 1 mg J9179 Injection, eribulin mesylate (Halaven), 0.1 mg J9202 Goserelin acetate implant (Zoladex ), per 3.6 mg J9217 Leuprolide acetate (for depot suspension)(eligard, Lupron Depot ), 7.5 mg J9225 Histrelin implant (Vantas ), 50 mg J9226 Histrelin implant (Supprelin LA), 50 mg Effective 04/01/2015 J9228 Injection, ipilimumab (Yervoy ), 1 mg J9263 Injection, oxaliplatin (Eloxatin ), 0.5 mg J9264 Injection, paclitaxel protein-bound particles (Abraxane ), 1 mg J9303 Injection, panitumumab (Vectibix), 10 mg J9305 Injection, pemetrexed (Alimta ), 10 mg J9310 Injection, rituximab (Rituxan ), 100 mg J9354 Injection, ado-trastuzumab emtansine (Kadcyla ), 1mg J9355 Injection, trastuzumab (Herceptin ), 10 mg Effective 07/20/2009

Q2043 Sipuleucel-T (Provenge ), minimum of 50 million autologous CD54+ cells activated with PAP-GM- CSF, including leukapheresis and all other preparatory procedures, per infusion Q2049 Injection, Doxorubicin Hydrochloride, Liposomal, Imported Lipodox (Lipodox ), 10mg Effective 04/01/2015 Q2050 Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10mg Effective 04/01/2015 Q5101 Injection, filgrastim, biosimilar, 1mcg Effective 07/01/2015 **NOTE - Depending upon the member s benefits drugs not covered under PADP may require prior authorization through Florida Blue. ** Additions to this list will be made periodically in accordance with applicable provisions of your contract(s). Additionally, certain member benefit agreements may require prior authorization for certain drugs. Note: The program is not applicable for drugs administered in an emergency room, observation unit or during an inpatient stay. Additionally, this program is not applicable for drugs ordered through Florida Blue Specialty Pharmacy Program (i.e. Just in Time, Drug Replacement ). As with all utilization management programs, PADP will be utilized to determine if the proposed service meets the definition of medical necessity under the member s benefit plan. Details of this pre-service review process are listed below. Requirements for the pre-service review process are applicable to the following products: HMO (BlueCare, BlueMedicare HMO) PPO (BlueChoice, BlueMedicare PPO, BlueOptions, BlueSelect, GoBlue, Miami-Dade Blue) State Employees' PPO Plan Traditional The PADP pre-service review process is unavailable for certain members including BlueCard, BlueMedicare PFFS, Medicare supplement and FEP. It is also not available for members whose primary coverage is Medicare or the secondary insurance coverage is Florida Blue.

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