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 718.536.3329) Brand Generic J-Code 1 Billable Unit Covered Uses Botox Onabotulinumtoxin A J0585 1 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 J0587 100units Cervical Dystonia Neurologic workup with previous methods tried Dysport Abobotulinumtoxin A J0586 5 units Xeomin Incobotulinumtoxin A J0588 1 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
Firazyr Icatibant J1744 Kalbitor Ecallantide J1290 1 mg Acute attacks of HAE Laboratory confirmation of HAE Administered by appropriate health care specialist Caverject Alprostadil J0270 1.25 mcg Diagnosis of Erectile Dysfunction (ED) Muse Aplrostadil urethral J0275 125 mcg Complete physical examination. Treatment of ED Registered Sex Offender Male infertility Pavacot Papaverine J2440 60 mg Oraverse Phentolamine J2760 5 mg Lupron Depot Lupron Leuprolide J1950 J9217 3.75 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 J9225 50 mg Prostate Cancer (PC) Laboratory confirmation PSA, Gleason Score. Disease staging
Supprelin LA Histrelin Implant J9226 50 mg Central Precocious Puberty Laboratory confirmation GnRH test, bone age assessment, imaging of the brain, age. Age < 2 Delayed puberty Makena Hydroxyprogesterone Caproate J1725 1 mg Reduce the risk of preterm birth in women, with a singleton pregnancy, who has a history of singleton spontaneous preterm birth. Xolair Omalizumab J2357 5 mg Moderate to severe persistent asthma (+) skin test reactive to perennial aeroallergen Inadequately controlled by corticosteroids. Synagis (Seasonal usage November-March) Palivizumab 90378 50 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 800-999-0225 or fax 516-240-1577 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
Cytogam J0850 50 ml Privigen J1459 500 mg J1460 1 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 J1557 500 mg infections -Authorizations trough IgG levels; documenting patient response to Ig. Hizentra J1559 100 mg Bone Marrow Gammaked J1561 500 mg Transplant: Bone Marrow Transplant Transplant Date of transplant, detailed patient history Gamunex Immune Globulin J1561 500 mg Kawasaki CBC Vivaglobin J1562 100 mg Serum ESR Serum C-reactive protein Serum LFTs Gammagard liquid J1566 500 mg
Octagam J1568 500 mg Hyperrho S/D J2788 50mcg/ 250 IU Carimune J1566 500mg Flebogamma J1572 500mg 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
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).