N/A N/A N/A. Supporting statement of diagnosis from the N/A. physician and documented trial of 1 generic. formulary alternative
|
|
- Hannah Rodgers
- 8 years ago
- Views:
Transcription
1 Actimmune Amlodipine Androderm Anticonvulsant Antidepressants Antineoplastics Antipsychotics Arcalyst Butalbital Colony Stimulating Factors ESRD Therapy Actimmune Norvasc Androderm Banzel Keppra Mysoline Neurontin Sabril Abilify Abilify Discmelt Pamelor Prozac Afinitor Avastin Gleevac Istodax Nexavar Revlimid Rituxan Spyrcel Sutent Tarceva Targretin Tasigna Thalomid Tretinoin Tykerb Velcade Vidaza Votrient Fanapt Arcalyst Fioricet w/cod Leukine Mozobil Neulasta Neupogen Procrit Supporting statement of diagnoisis from the and ANC requirement (less than or equal to 1000 cells/mm3). For PA extension, need to provide new labs (WBC Hemogloblin less than 10 g/dl for patients receiving Cancer Chemotherapy and Hemoglobin less than 12 and Hematacrit less than 33 for other approved FDA indications in addition to supporting statement of diagnosis from 3 months 3 months Exjade Exjade Fenofibrate Lipofen Lofibra 12/31/2012 Last Updated: 09/21/2011 Page 1 of 7
2 Fentanyl Fentanyl Lozenge Fentora Firmagon Fosamax Gamunex Growth Hormone Hepatitis C Hydrocodone Imitrex Imuran Kuvan Fentora Onsolis Firmagon Fosamax Gamunex Humatrope Nutropin Nutropin AQ Omnitrope Saizen Serostim Infergan Pegasys Pegintron Ribapak Ribavirin Lorcet Lortab Norco Imitrex Imuran Kuvan, submission of pretreatment viral titers (HCV RNA) and genotype. For genotypes 1 and 4 submission of documentation of RNA load at 12 weeks 12/31/ weeks Letairis Letairis Lidoderm Lidoderm Loprox Lupron Marinol Mestinon Minocycline Mirapex Loprox Leuprolide Acetate Lupron Depot Lupron Depot-Ped Marinol Mestinon Minocin Oracea Solodyn Mirapex 12/31/2012 Last Updated: 09/21/2011 Page 2 of 7
3 Mobic Mobic MS Contin Multiple Sclerosis Nifedipine Noxafil Octreotide Oxandrolone Oxycodone Parlodel Pravachol Prilosec Privigen Proscar Provigil Razadyne Revatio Rheumatoid Ritalin Samsca MS Contin Ampyra Avonex Betaseron Rebif Rebif Titration Pack Procardia Noxafil Octreotide Acetate Sandostatin Oxandrin Oxycontin Percocet Percodan Roxicodone Parlodel Pravachol Prilosec Privigen Proscar Nuvigil Provigil Razadyne Revatio Enbrel Humira Humira Pen-Crohns Kineret Orencia Simponi Ritalin Samsca 12/31/ /31/ /31/2012 Last Updated: 09/21/2011 Page 3 of 7
4 Sinemet Sinemet Soma Somatuline Fexmid Soma Somatuline Somavert Somavert Sonata Sporanox Symlin Terbinafine Sonata Sporanox Sporanox Pulsepack Symlin Symlinpen Terbinafine 12/31/2012 Tracleer Tracleer Uloric Uloric Xenazine Xenazine Xolair Xolair Zolinza Zolinza Last Updated: 09/21/2011 Page 4 of 7
5 Albuterol Sulfate Albuterol/Ipratropium Alimta Amifostine Aminosyn Aminosyn/Electrolyte Aminosyn/Dextrose Aminosyn M Aminosyn-HBC Aminosyn-HF Aminosyn-PF AMPHOTERICIN B Ampicillin/Sulbactam Arzerra Atgam Azathioprine Bleomycin Sulfate Busuflex This drug may be covered under Calcitonin-Salmon Medicare Part B or D depending Calcitrol upon the circumstances. Part B/D Drugs Cellcept Information may need to be Drugs A through F Cerezyme submitted describing the use and Chlorpromazine hcl setting of the drug to make the Clinimix/Dextrose determination. Clinimix E/Dextrose Clinisol SF Colistimathate Sodium Copaxone Cromolyn Sodium Cyclophosphamide Cyclosporine Cyclosporine Modified Dextrose/NACL Doxycyline Dronabinol Etoposide Fabrazyme Fluconazole Fortical Foscarnet Sodium Freamine III Last Updated: 09/21/2011 Page 5 of 7
6 Gamastan S/D Gammagard Liquid Gemzar Gengraf Granisetron hcl Granisol Hectoral HECTOROL Heparin Sodium Heparin Sodium DCU Hepatamine Hycamtin Idamycin Idarubicin hcl Ifex Ifosfamide/Mesna Ifosfamide Ipratropium Bromide KCL/D5W/LR Leucovorin Leustatin Levalbuterol This drug may be covered under Levocartine Medicare Part B or D depending Melphalan upon the circumstances. Part B/D Drugs Mesna Information may need to be Drugs G through P Mesnex submitted describing the use and Miacalcin setting of the drug to make the Mitoxantrone hcl determination. Mustargen Mycophenolate Mofetil Myfortic Nebupent Neoral Nephramine Nipent Novantrone Ondansetron, Ondandestron ODT Orthoclone Oxaliplatin Paclitaxel Pentam Pentostatin Performist Premasol Procalamine Prochlorperazine Maleate Prograf Prosol Pulmicort Pulmozyme Last Updated: 09/21/2011 Page 6 of 7
7 Rapamune Rocaltrol Sancuso Sandimmune Simulect Sodium Chloride Tacrolimus This drug may be covered under Thymoglobulin Medicare Part B or D depending Tobi upon the circumstances. Part B/D Drugs Torisel Information may need to be Drugs R through Z Travasol submitted describing the use and Trisenox setting of the drug to make the Vancocin hcl determination. Vancomycin hcl Ventavis Vivaglobin Zemplar Zometa Zortress Last Updated: 09/21/2011 Page 7 of 7
Drugs covered under Medicare Part B or Part D
LABEL_NAME GENERIC_NAME MESSAGE GEMZAR INJ 1 GM GEMCITABINE HCL FOR INJ 1 GM ALIMTA INJ 500MG PEMETREXED DISODIUM FOR IV SOLN 500 MG (BASE EQUIV) FUNGIZONE INJ 50MG AMPHOTERICIN B FOR INJ 50 MG KYTRIL
More informationSpecialty Drug Program RX Benefit Member Guide
Specialty Drug Program RX Benefit Member Guide bcbsm.com Enrollment Form for Walgreens Specialty Pharmacy, LLC. How to place your initial order with Walgreens Specialty Pharmacy: 1) Print and complete
More informationHumana 2015 Autorización previa
Humana 2015 Autorización previa Los medicamentos a continuación requerirán autorización previa en 2015. Para información sobre el nivel de copago, visite Humana.com. Abstral 100 mcg sublingual tablet Abstral
More informationREVISING SPECIALTY TIERS
WHITE PAPER REVISING SPECIALTY TIERS PROTECTING MEDICARE PART D BENEFICIARIES FROM BURDENSOME COST SHIFTING Gary G., Michigan Gary thought he had his financial assistance grant set up to cover his out-of-pocket
More informationAlameda Alliance for Health SPECIALTY PHARMACY PROGRAM FOR ALLIANCE MEDI-CAL AND GROUP CARE MEMBERS PROGRAM DESCRIPTION
Alameda Alliance for Health SPECIALTY PHARMACY PROGRAM FOR ALLIANCE MEDI-CAL AND GROUP CARE MEMBERS PROGRAM DESCRIPTION Contents Page Program Overview 1 Process for Obtaining Authorization 2 Contacts 2
More informationSTAT Bulletin. Drug Therapy Guideline Updates. May 11, 2012 Volume: 18 Issue: 12
STAT Bulletin May 11, 2012 Volume: 18 Issue: 12 To: All primary care physicians and specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat What
More informationPrescription Drug Benefit Description
Prescription Drug Benefit Description Herein called Description Prescription Drug Program For State of Kansas Employees Health Plan This booklet describes the Prescription Drug benefits available through
More informationSpecialty Pharmacy. Business Plan. July 8, 2013. 2013 RUSH University Medical Center
Specialty Pharmacy Business Plan July 8, 2013 Specialty Pharmaceuticals What are they? Biotech/gene-based therapy Require special handling Newer products oral or self- administered One third have REMS
More informationDrugs Requiring Prior Authorization. Olysio. Subsys. Prolia. Tecfidera
Abstral Acthar Hp Adcirca Adempas Affinitor Amitiza Amitriptyline Ampyra Androgel Androderm Androxy Aranesp Arcalyst Aubagio Avonex Bosulif Bydureon Byetta Cimzia Cinryze Clomipramine Cometriq Copaxone
More informationSpecialty Pharmacy: Understanding the Market and Solution. Your Goals. Presented by Chris Brown November 2009
Specialty Pharmacy: Understanding the Market and Solution Presented by Chris Brown November 2009 Your Goals What What is a Specialty is a specialty Medication? medication? Specialty drugs are injectable,
More informationDrugs That Require Prior Authorization (PA) Before Being Approved for Coverage PRIOR AUTHORIZATION MEDICATIONS
That Require Prior Authorization (PA) Before Being Approved for Coverage PRIOR AUTHORIZATION MEDICATIONS ACNE Approve for those 12 years of age and older AVITA, RETIN-A MICRO, TRETINOIN ACTHAR HP All FDA-approved
More information4Precertification. and Referrals. Precertification...59 Referrals (Gated Plans Only)...73
4Precertification and Referrals Precertification.....................59 Referrals (Gated Plans Only)............73 Section 4 Precertification and Referrals 58 www.oxfordhealth.com Precertification and
More informationFor renewals, patient must have responded to Actemra therapy (e.g., condition improved or stabilized).
PA Criteria ACTEMRA ACTEMRA Active infection (including TB). Concurrent therapy with other biologic agent(s). Screening for latent tuberculosis is required. If results are positive, patient must have completed
More informationThe Basics of Pharmacy Benefits Management (PBM) 2009
The Basics of Pharmacy Benefits Management (PBM) 2009 Andrew Kingery Pharmacy Account Management Virginia CE Forum 2009 Course# 201719 Objectives & Introduction Provide basic components of a PBM Define
More informationHealthPartners, Inc. 2013 Medicare Part D Formulary ID 13142, Version 22 Prior Authorization Criteria. Last Updated: 11/01/2013
ACTEMRA Actemra (1) DIAGNOSIS OF MODERATELY TO SEVERELY ACTIVE RHEUMATOID ARTHRITIS, OR (2) JUVENILE IDIOPATHIC ARTHRITIS, AND (3) DOCUMENTATION OF MEDICAL CONTRAINDICATIONS OR FAILURE WITH ENBREL OR HUMIRA.
More informationSpecialty drug trend
2 0 0 8 Specialty drug trend r e p o r t Specialty Pharmacy A n E x p r e s s S c r i p t s C o m p a n y Lead Authors Emily Cox, PhD, RPh Yakov Svirnovskiy, MA Chris Peterson, PharmD Aimee Tharaldson,
More informationHMO and PPO Updates May 2013- Commercial Results
HMO and PPO Updates May 2013- Commercial Results ELIQUIS Non Triple Tier Formular y 4th Tier Applicable Traditional Alternatives warfarin, Xarelto, Pradaxa TAMIFLU - EXPANDED INDICATION 2 No 2 No No None
More informationCONNECTICARE, INC. & AFFILIATES
CONNECTICARE, INC. & AFFILIATES INSERT PAGE FOR PRE-CERTIFICATION AND PRE- AUTHORIZATION LISTS UPDATE Applies to all ConnectiCare health plans, except the ConnectiCare Network USA-PPO Plan and as otherwise
More informationCOVERAGE MANAGEMENT PROGRAMS
COVERAGE MANAGEMENT PROGRAMS The purpose of coverage management programs is to help improve the quality of care by encouraging the right patient and provider behaviors to avoid compromised care and unnecessary
More informationPrior Authorization Requirements Effective: 12/01/2015
An Independent Licensee of the Blue Cross and Blue Shield Association Prior Authorization Requirements Effective: 12/01/2015 No changes made since 10/2015 AMPYRA AMPYRA PLUS PATIENT ALREADY STARTED ON
More informationPain management for cancer patients Acute Ischemic Stroke. Hemophilia, Von willebrand disease & Bleeding disorders. Infectious Disease
Cigna Specialty Pharmacy Services Limited Distribution and Risk Evaluation Mitigation (RE) Drug List Last updated on 04/06/2015 Medication Brand Name Condition Actemra Rheumatroid Arthritis Acthar Seizure
More informationMedicare Part D Plans Deliver Significant Savings on Innovative, Breakthrough Medicines
Medicare Part D Plans Deliver Significant Savings on Innovative, Breakthrough Medicines Survey Finds Private Sector Negotiations Provide Both Savings and Choice, Making Government Interference Unnecessary
More informationLocal Coverage Article: Self-Administered Drug Exclusion List (A51866)
Local Coverage Article: Self-Administered Drug Exclusion List (A51866) Contractor Information Contractor Name Novitas Solutions, Inc. Article Information General Information Article ID A51866 General Article
More informationPrescription Drug Benefit
Prescription Drug Benefit The Cleveland Clinic Employee Health Plan (EHP) Total Care Prescription Drug Benefit is administered through CVS Caremark. CVS Caremark has a dedicated, toll-free Customer Service
More informationPrior Authorization FID 16157 VER.7 UPDATED 8/2015
Prior Authorization FID 16157 VER.7 UPDATED 8/2015 Prior Authorization 2016 MAPD Leon 3 Tier Last Updated: 10/22/2015 ACTEMRA Products Affected Actemra INJ 162MG/0.9ML PA Details Other 1 ACTIMMUNE Products
More informationCoverage and Pricing. of Drugs That Can Be Covered Under. Part B and Part D
Coverage and Pricing Elizabeth Hargrave NORC at the University of Chicago Jack Hoadley of Drugs That Can Be Covered Under Part B and Part D Jennifer Thompson Georgetown University MedPAC A study conducted
More informationPrescription Drug Utilization and Cost Trends, 2009-2013
Agenda Item 7 Attachment 1 Prescription Drug Utilization and Cost Trends, 2009-2013 Pension and Health Benefits Committee October 14, 2014 Melissa Mantong, PharmD CalPERS Pharmacist Overview Trends in
More informationICORE Healthcare: Injectable Drug Utilization Management Program Overview for EmblemHealth Providers. May 1, 2012
ICORE Healthcare: Injectable Drug Utilization Management Program Overview for EmblemHealth Providers May 1, 2012 Agenda Topics for Today 1. Program Summary Specialty Injectable Drugs in scope EmblemHealth
More informationGreat-West s Drug Prior Authorization
Great-West s Drug Prior Authorization Great-West Life s prior authorization process is designed to provide an effective approach to managing claims for specific prescription drugs. Approval for coverage
More informationAuthorized by the U.S. District Court for the District of Massachusetts
Authorized by the U.S. District Court for the District of Massachusetts If you made a Cash Payment or Percentage Co-Payment for Certain Drugs, from January 1, 1991 to March 1, 2008, you may be able to
More informationMay 31, 2013. Ms. Debra Lansey American College of Physicians 190 North Independence Mall West Philadelphia, PA 19106
P.O. Box 30449 Salt Lake City, UT 84130-0449 May 31, 2013 Ms. Debra Lansey American College of Physicians 190 North Independence Mall West Philadelphia, PA 19106 Re: Pharmacy Benefit Coverage Changes Effective
More informationencourages correct prescription drug use for a particular diagnosis, promotes the safe use of prescription drugs, and helps reduce drug costs.
Prior Authorization Your health plan participates in a Prior Authorization (PA) program for specific prescription drugs. This means that Caremark must review certain information provided by your doctor
More informationSelf-injectable, infused and oral specialty drugs 2014 Aetna Specialty CareRx SM Benefits Plan Drug List
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Self-injectable, infused and oral specialty drugs 2014 Aetna Specialty CareRx SM Benefits Plan Drug List 05.03.382.1
More informationMultiple Sclerosis Center of Nebraska
Multiple Sclerosis Center of Nebraska Date: Initial Visit Patient Information (Multiple Sclerosis) To be Completed Before Appointment Patient Name: DOB: Address: Social Security Number: Power of Attorney
More informationDrug List Limitations, Exclusions and Preauthorization Criteria
Blue Cross and Blue Shield of New Mexico (BCBSNM) provides coverage of many drugs for our members. Effective communication about specific drug limitations is important for consistent benefit administration
More informationWendy Clary Nash, PharmD BCPS CPG FASCP. Neil Medical Group Sept 30, 2014
Wendy Clary Nash, PharmD BCPS CPG FASCP Neil Medical Group Sept 30, 2014 Do you feel like You re in a daze? A healthcare craze? A medication maze? Quack, Quack If it walks like a duck, talks like a duck
More informationfor Extended Stability Parenteral Drugs Third Edition Caryn M. Bing, R.Ph., M.S., FASHP Editor
Extended Stability for Parenteral Drugs Third Edition Editor Caryn M. Bing, R.Ph., M.S., FASHP 1 American Society of Health-System Pharmacists Bethesda, Maryland Contents Preface Acknowledgments x/ Dedication
More information2013 Prior Authorization (PA) Criteria
2013 Prior Authorization (PA) Criteria Certain drugs require prior authorization from EmblemHealth Medicare PDP Medicare Plans. This means that your doctor must contact us to get approval before prescribing
More informationImmune 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:
More informationACTEMRA. Step Therapy Criteria HEALTH CHOICE EXCHANGE 2016 Effective Date: 01/01/2016. PRODUCT(s) AFFECTED ACTEMRA
ACTEMRA ACTEMRA Claim will pay automatically for Actemra if enrollee has a paid claim for at least a 1 days supply of Enbrel and Humira in the past 365 days. Otherwise, Actemra requires a step therapy
More informationSafety Policy Manual Policy No. 106
Safety Policy Manual Policy No. 106 Policy: Hazardous Drugs (Including Chemotherapeutic) Page 1 of 11 APPLICATION NYU Langone Medical Center (NYULMC) PURPOSE To protect employees from exposure to hazardous
More informationJanuary 1, 2016 At A Glance. CSEA Civil Service Employees Association
January 1, 2016 At A Glance CSEA Civil Service Employees Association For Employees of the State of New York represented by Civil Service Employees Association (CSEA) and for their enrolled Dependents;
More informationPlan Year 2016. Vantage Health Plan (HMO) Prior Authorization (PA) Criteria
Plan Year 2016 Vantage Health Plan (HMO) Prior Authorization (PA) Criteria Prior Authorization: Vantage Health Plan requires you (or your physician) to get prior authorization for certain drugs. This means
More informationACTEMRA. Cigna Medicare Rx (PDP) 2014 Cigna Medicare Rx Secure Plan (PDP) Formulary. Products Affected Actemra. Prior Authorization Criteria
Cigna Medicare Rx (PDP) Medicare Part D Prescription Drug Plans 2014 Cigna Medicare Rx Secure Plan (PDP) Formulary Prior Authorization ACTEMRA Products Affected Actemra PA Details Age Other Authorization
More informationInventory of Access and Prices of Orphan Drugs across Europe:
www.eurordis.org Inventory of Access and Prices of Orphan Drugs across Europe: A Collaborative Work between National Alliances on Rare Diseases & Eurordis Yann Le Cam Chief Executive Officer, EURORDIS
More informationProvider Manual. This manual is to help you learn more about The Ohio State University s medical plans, administered by OSU Health Plan Inc.
2014 Provider Manual This manual is to help you learn more about The Ohio State University s medical plans, administered by OSU Health Plan Inc. We hope you find this information and the enclosed documents
More informationACNE PRODUCTS. Affected Drugs: Epiduo Retin-A Tretinoin. Covered Uses: All FDA-approved indications not otherwise excluded from Part D
ACNE PRODUCTS Epiduo Retin-A Tretinoin Exclusion Criteria: Esthetic purposes N/A N/A TSA 2015 Royal, Classic, Vital and Vital Plus Formulary Page 1 of 148 ACTEMRA Actemra Exclusion Criteria: 1) Active
More informationEffective January 1, 2016
Effective January 1, 2016 CONTENTS Prescription Benefit Changes...2 2016 Prescription Drug Benefit Highlights...3 Comparing Your Options...4 Filling Your Prescriptions...4 Benefit Coverage Tiers...5 Prescription
More informationSUMMARY PLAN DESCRIPTION 2014-2015 STUDENT HEALTH PLAN Designed Especially for Students of
SUMMARY PLAN DESCRIPTION 2014-2015 STUDENT HEALTH PLAN Designed Especially for Students of Table of Contents Privacy Policy 3 Eligibility 3 Qualifying Event 3 Effective and Termination Dates 3 General
More informationMedicare Part D Drugs that Require Prior-Authorization Effective 12/01/2015
Medicare Drugs that Require Prior- Effective 12/01/2015 Prior Actemra IV Actemra All FDAapproved Required Medical Information Age Prescriber 2. For Rheumatoid Arthritis: Patient must have tried and failed
More informationApril 30, 2009. The Honorable Edward M. Kennedy Chairman Committee on Health, Education, Labor, and Pensions United States Senate
United States Government Accountability Office Washington, DC 20548 April 30, 2009 The Honorable Edward M. Kennedy Chairman Committee on Health, Education, Labor, and Pensions United States Senate Subject:
More informationExcluded Drug Criteria. Coverage Duration. Age Restrictions. Prescriber Restrictions. Prior Authorization Type Description.
2015 Cigna-HealthSpring - H0354 - Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Achieve Plus (HMO SNP), Cigna- HealthSpring Preferred Plus (HMO) (Updated December 2015) Name Other ABELCET ABRAXANE
More information2016 Formulary Annual Notice of Change
2016 Formulary Annual Notice of Change Updated: October 1, 2015 Medicare Advantage Employer Group Plans (EGWP) This is a listing of the changes that have occurred to the 2016 MAPD formulary. For a complete
More informationMEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Hepatitis C Agents
MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF PHARMACEUTICAL SERVICES I. Requirements for Prior Authorization of Hepatitis C Agents A. Prescriptions That Require Prior Authorization Prescriptions for Interferon,
More information22 Medicare Provider Manual
22 Medicare Provider Manual Table of Contents Title Page Introduction 2 Important Contact Information 4 Member Eligibility & Plan Design 5 ID card sample 8 Provider Reconsideration Process 9 Member Grievance
More informationMEDICAL ASSISTANCE BULLETIN
ISSUE DATE August 20, 2015 SUBJECT EFFECTIVE DATE September 28, 2015 MEDICAL ASSISTANCE BULLETIN NUMBER 99-15-08 BY Specialty Pharmacy Drug Program Pharmacy Services Leesa M. Allen, Deputy Secretary Office
More informationPrescription Access resources. NeedyMeds. RxAssist.org. Together RX Access 800-444-4106. TogetherRxAccess.com
Prescription Access resources NeedyMeds RxAssist.org Together RX Access 800-444-4106 TogetherRxAccess.com The Partnership for Prescription Access 888-4PPA-NOW (888-477-2669) www.pparx.org By Company: ABBOTT
More informationBCBSNM Drug List Limitations, Exclusions, and Preauthorization Criteria
The Blue Cross and Blue Shield of New Mexico (BCBSNM) Pharmacy Benefit provides coverage of most drugs for our members. Effective communication about specific drug limitations is important for consistent
More informationHPMS Approved Formulary File Submission ID: 00016311, Version Number 6.
UPMC for Life 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00016311, Version
More informationUPMC for You Advantage (HMO SNP) 2015 Formulary. (List of Covered Drugs)
UPMC for You Advantage (HMO SNP) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID:
More informationPlan Year 2016. Allegian Advantage (HMO) Prior Authorization (PA) Criteria
Plan Year 2016 Allegian Advantage (HMO) Prior Authorization (PA) Criteria Prior Authorization: Allegian Advantage requires you (or your physician) to get prior authorization for certain drugs. This means
More informationCommercial Medicines Unit
Commercial Medicines Unit Procurement guidance For The provision of homecare delivery service of medicines to patients at home Issue date: May 2011 Review date: Sep 2012 1 September 2012 Crown Copyright
More informationPrior Authorization Criteria 2014
Prior Authorization Criteria 2014 For information on obtaining an updated coverage determination or an exception to a coverage determination please contact Easy Choice Health Plan of New York s Member
More informationStudent Employee Health Plan (SEHP) for Graduate Student Employees
New York State Health Insurance Program Student Employee Health Plan (SEHP) for Graduate Student Employees January 1, 2009 For Graduate Student Employees and for their enrolled Dependents and for COBRA
More informationHydration, IV Infusions, Injections and Vaccine Charge Process
There are a number of items to be considered when billing for the Nursing service to perform drug therapy, the charge process is divided into three specific groups of codes and processes. 1. Hydration
More informationPreventing and Treating Nausea and Vomiting Caused by Cancer Treatment
A Patient s Guide Preventing and Treating Nausea and Vomiting Caused by Cancer Treatment Recommendations of the American Society of Clinical Oncology The American Society of Clinical Oncology (ASCO) is
More informationSales Agent Field Guide
Sales Agent Field Guide Humana Medicare Supplement Plans Humana.com GH16094M10 Contents Humana - Who We Are Agent Information Agent Conduct Licensing and Appointment for Humana's Agents Humana Medicare
More informationMedicare Part D Drugs Requiring Prior Authorization
Formulary ID 14068, Version 17 Last Updated 11/2014 Y0051_1622_508 Accepted 09/14/2012 Medicare Part D Drugs Requiring Prior Authorization MVP Health Care requires you or your doctor to get prior authorization
More informationEffective Date: 6/3/14
North Shore-Long Island Jewish Health System, Inc. Long Island Jewish Medical Center PATIENT CARE SERVICES POLICY TITLE: ORDERING, ADMINISTRATION AND DISPOSAL OF ORAL CHEMOTHERAPEUTIC AGENTS Prepared by:
More informationGUIDE TO PRESCRIPTION DRUG BENEFITS. Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
GUIDE TO PRESCRIPTION DRUG BENEFITS Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association TABLE OF CONTENTS 1 Contact Us Phone Number Website 2-3 Using Your Prescription
More informationCytokine and CAM Antagonists
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Actemra (Tocilizumab) Drugs requiring prior authorization: the list of drugs
More informationNews & Views. Dose Optimization Limitations for Mental Health Medications
Maryland Medicaid Pharmacy Program News & Views May 2010 Maryland Department of Health and Mental Hygiene /Office of Systems, Operations and Pharmacy Antipsychotics on Maryland Medicaid PDL and Coverage
More informationJanuary 1, 2014. Participating Agencies
January 1, 2014 PA Participating Agencies For Active Employees, Retirees, Vestees and Dependent Survivors, Enrollees covered under Preferred List Provisions, their Dependents, COBRA enrollees and Young
More informationThis information is also available in large print. Call 1-800-286-4242. TTY users should call toll-free 1-800-361-2629.
Your prescription drug program 2015 This information is also available in large print. Call 1-800-286-4242. TTY users should call toll-free 1-800-361-2629. Table of Contents Your Prescription Drug Program...
More informationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
UPMC for Life 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00015350, Version
More informationMedical Prior Authorization List For prescription drug requirements, see plan formularies.
For prescription drug requirements, see plan formularies. General Information These requirements are administered by Health First Health Plans ( Health Plans ). Benefits are determined by the plan. Items
More information2016 Prior Authorization Requirements
Group Health Medicare Advantage HMO 2016 PLEASE READ: Group Health requires you to get prior authorization for certain drugs. This means that you will need to get approval from Group Health before you
More informationPA Criteria Prior Authorization Group ABILIFY MAINTENA
PA Criteria ABILIFY MAINTENA ABILIFY MAINTENA Patient has a diagnosis of dementia-related psychosis. ACTEMRA ACTEMRA Active infection (including active TB). Combination therapy with another biologic agent.
More informationMedication Guide Korlym (KOR-lim) (mifepristone) tablets
Medication Guide Korlym (KOR-lim) (mifepristone) tablets Read this Medication Guide before you start taking Korlym and each time you get a refill. There may be new information. This information does not
More informationMercyCare Prescription Drug Policies & Coverage Criteria 1 11/1/14
MercyCare Prescription Drug Policies & Coverage Criteria 1 11/1/14 Table of Contents Introduction Pg 3 Contact Information Pg 3 Formulary Key Pg 4 Co-pay Structure Explanation Pg 5 Covered Drugs Pg 6 Covered
More informationAvMed Medicare Choice
AvMed Medicare Choice 2016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary
More informationVA Premier CompleteCare Drugs that Require Step Therapy Last Updated: 09/23/2014
Atelvia Atelvia Claim will pay automatically for Atelvia if enrollee has a paid claim for at least a 1 days supply of alendronate in the past 365 days. Otherwise, Atelvia requires a step therapy exception
More informationProduct Catalog. 65862-0073-60 Abacavir Tablets 300 mg 60 80 80 AB Ziagen Yellow
65862-0073-60 Abacavir Tablets 300 mg 60 80 80 AB Ziagen Yellow 13107-0058-01 Acetaminophen & Codeine Tablets, C-III 300 mg / 15 mg 100 216 216 AA Tylenol-Codeine White/Off-White 13107-0059-01 Acetaminophen
More informationAUBAGIO. Step Therapy Criteria Health Choice Generations Formulary ID: 15179 Version 19 Effective Date: 11/1/2015. PRODUCT(s) AFFECTED AUBAGIO
AUBAGIO AUBAGIO Claim will pay automatically for AUBAGIO if enrollee has a paid claim for at least a 1 days supply of COPAXONE, REBIF, TYSABRI, BETASERON OR EXTAVIA in the past 365 days. Otherwise, AUBAGIO
More informationEmpire MediBlue Plus (HMO) 2015 Formulary (List of Covered Drugs)
Empire MediBlue Plus (H) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on October, 0. For more
More informationPrescription Drug Summary Plan Description
Prescription Drug Summary Plan Description About This Summary Plan Description (SPD) The Prescription Drug Program is a component program in the Tenet Employee Benefit Plan (TEBP). The TEBP is a comprehensive
More informationHow To Treat Rheumatoid Arthritis
Pharmacy Prior Authorization Non-Formulary, Prior Authorization and Step-Therapy Guidelines Scroll down to see PA Criteria by drug class, or Ctrl+F to search document by drug name Non-Formulary Medication
More informationPATIENT ASSISTANCE PROGRAMS
PATIENT ASSISTANCE PROGRAMS Definitions SAP Class I Class II BC Cancer Agency Health Canada Special Access Program Reimbursed for active cancer or approved treatment or approved indication only Reimbursed
More informationMEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Hepatitis C Agents
MEDICAL ASSISTANCE HBOOK I. Requirements for Prior Authorization of Hepatitis C Agents A. Prescriptions That Require Prior Authorization Prescriptions for Hepatitis C Agents that meet any of the following
More informationP&T Committee Meeting Minutes (GHP Family Business) March 18, 2014
P&T Committee Meeting Minutes (GHP Family Business) March 18, 2014 Present: Bret Yarczower, MD, MBA Chair Peter Mikhail, Pharm.D., MBA Secretary Charles Baumgart, MD, MBA Keith Boell, DO Kimberly Clark,
More informationExpress Scripts/Medco Prescription Plan Information For Drug Coverage Review, Prior Authorization Process and Personalized Medicine Information
Express Scripts/Medco Prescription Plan Information For Drug Coverage Review, Prior Authorization Process and Personalized Medicine Information The endowed health plan offers faculty and staff members
More informationACS CAN Examination of Cancer Drug Coverage and Transparency in the Health Insurance Marketplaces
ACS CAN Examination of Cancer Drug Coverage and Transparency in the Health Insurance Marketplaces Executive Summary November 18, 2015 In 2014, the American Cancer Society Cancer Action Network (ACS CAN)
More informationMedical School for Actuaries. June 12, 2013. Baltimore, Maryland
Medical School for Actuaries June 12, 2013 Baltimore, Maryland Developments in the Treatment of Conditions Treated with Specialty Mediations (Cancer, MS, RA, Hemophilia) Mark S. Matusik, PharmD Developments
More informationHow To Get A Generic Drug From A Pharmacy Benefit Manager
Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative
More informationAubagio. AgeWell Drugs that Require Step Therapy Last Updated: 08/08/2014. Products Affected. Details AUBAGIO TAB 14MG AUBAGIO TAB 7MG
Aubagio AUBAGIO TAB 14MG AUBAGIO TAB 7MG Claim will pay automatically for AUBAGIO if enrollee has a paid claim for at least a 1 days supply of COPAXONE, REBIF, TYSABRI, BETASERON OR EXTAVIA in the past
More informationBuilding A Fully Integrated Biotech Company:
BIOPHARMA BIOPHARMA STRATEGIES STRATEGIES Building A Fully Integrated Biotech Company: WHAT IT TAKES The transition from R&D to a fully integrated stage is a make-orbreak scenario for any biotech company.
More informationthe FDA. The FDA MedWatch form is available at: http://www.fda.gov/downloads/safety/medwatch/howtoreport/downloadforms/ucm082725.
Pharmacy Prior Authorization Non-Formulary, Prior Authorization and Step-Therapy Guidelines Scroll down to see PA Criteria by drug class, or Ctrl+F to search document by drug name Non-Formulary Medication
More informationAbridged Formulary 2016 (Partial List of Covered Drugs)
Abridged Formulary 2016 (Partial List of Covered Drugs) THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Indiana University Health Plans Medicare Choice HMO-POS Indiana University
More informationAGENT UNDERWRITING GUIDE FOR MEDICARE SUPPLEMENT
AGENT UNDERWRITING GUIDE FOR MEDICARE SUPPLEMENT Marketing Support, Agent Licensing, Supplies: 1-866-708-6194 Customer Service, Claims, Underwriting: 1-800-877-7703 New Business Fax: 713-583-2738 Commissions:
More information