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  • /app/files/public/7854/Aripiprazole-Abilfy-Maintena-MP9456.pdf ABILIFY MAINTENA (aripiprazole) Show Details
    Description
    ABILIFY MAINTENA (aripiprazole) MP9456 (Code J0401)
    Last Updated
    7/27/2017
  • /app/files/public/4641/pdf-medicalpolicies-9202Abor.pdf Abortions (Surgical or Pharmacological) Show Details
    Description
    (MP9202) Prior authorization through the Medical Affairs Division is required to determine whether an abortion will be covered on the grounds of medical necessity.
    Last Updated
    2/13/2014
  • /app/files/public/4593/pdf-medicalpolicies-9023Acne.pdf Acne Show Details
    Description
    (MP9023) Dean Health Plan's Medical Policy on the treatment of Acne. (Related: dermabrasion, collagen, hyperbaric, photodynamic therapy, acne vulgaris, cystic acne, Dermatology)
    Last Updated
    2/13/2014
  • /app/files/public/4766/pdf-medicalpolicies-9405Tocilizumab.pdf ACTEMRA (tocilizumab) IV Show Details
    Description
    ACTEMRA (tocilizumab) IV (MP9405) (Code J3262)
    Last Updated
    7/27/2017
  • /app/files/public/7718/Tocilizumab-ACTEMRA.pdf ACTEMRA (tocilizumab) SQ Show Details
    Description
    ACTEMRA (tocilizumab) SQ (PA9895) is an interleukin-6 (IL-6) receptor antagonist used to treat moderate to severe rheumatoid arthritis. This is the policy when the pharmacy benefit applies.
    Last Updated
    10/11/2016
  • /app/files/public/3882/pdf-providers-Tadalafil_ADCIRCA_9883.pdf ADCIRCA (tadalafil) Show Details
    Description
    ADCIRCA (tadalafil) (PA9883) is a phosphodiesterase type 5 (PDE-5) inhibitor for pulmonary arterial hypertension (PAH).
    Last Updated
    10/11/2016
  • /app/files/public/7721/Riociguat-ADEMPAS.pdf ADEMPAS (riociguat) Show Details
    Description
    ADEMPAS (riociguat) is a soluble guanylate cyclase (sGC) stimulator used to treat Persistent/Recurrent Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and Pulmonary Arterial Hypertension (PAH).
    Last Updated
    10/11/2016
  • /app/files/public/3707/pdf-providers-Everolimus_AFINITOR_9873.pdf AFINITOR (everolimus) Show Details
    Description
    AFINITOR (everolimus) PA9873 is a mammalian target of rapamycin (mTOR) inhibitor, FDA approved for the treatment of advanced renal cell carcinoma after failure of sorafenib or sunitinib.
    Last Updated
    10/10/2016
  • /app/files/public/9877/ALDURAZYME-laronidase-PA9940.pdf ALDURAZYME (laronidase) Show Details
    Description
    ALDURAZYME (laronidase) PA9940 (Code J1931)
    Last Updated
    8/1/2017
  • /app/files/public/9418/ALECENSA-alectinib-PA9924.pdf ALECENSA (alectinib) Show Details
    Description
    ALECENSA (alectinib) is used to treat metastatic non-small cell lung cancer and must be prescribed by Oncology or Hematology specialists. Prior authorization is required
    Last Updated
    8/1/2017
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