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Drug Policies

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Documents for Drug Policies

  • /app/files/public/8484/DHP9457-abatacept-ORENCIA.pdf Abatacept (ORENCIA) IV Show Details
    Description
    ORENCIA requires prior authorization through Navitus and is considered medically appropriate when one of the following are met: Adult patients with active rheumatoid arthritis who have had an inadequate response TNF antagonist therapies. OR Patient must have a trial of therapy with infliximab (REMICADE) or golimumab (SIMPONI ARIA). ORENCIA is restricted to Rheumatology Specialists.
    Last Updated
    6/14/2016
  • /app/files/public/4783/pdf-medicalpolicies-Abatacept_ORENCIA_9846.pdf Abatacept (ORENCIA) SQ Show Details
    Description
    Abatacept (ORENCIA) PA9846 A selective immune modulator approved for treatment of moderate to severe rheumatoid arthritis (RA) in patients with inadequate responses to one or more disease-modifying anti-rheumatic drugs (DMARDs).
    Last Updated
    6/14/2016
  • /app/files/public/3611/pdf-providers-Adalimumab_HUMIRA_9822.pdf Adalimumab (HUMIRA) Show Details
    Description
    Adalimumab (HUMIRA) PA9822 A recombinant human IgG1 monoclonal antibody specific for human tumor necrosis factor TNF. (Related: rheumatoid arthritis, RA, juvenile rheumatoid arthritis (JRA), Crohn’s Disease, psoriasis)
    Last Updated
    9/22/2015
  • /app/files/public/4690/pdf-medicalpolicies-9300Agalsidase.pdf Agalsidase (FABRAZYME) Show Details
    Description
    Agalsidase (FABRAZYME) MP9300 is administered every 2 weeks in the physician’s office is considered medically appropriate for the treatment of Fabry’s Disease and requires prior authorization.
    Last Updated
    6/14/2016
  • /app/files/public/6445/DHP9446_AAT.pdf Alpha 1 Antitrypsin Inhibitors Show Details
    Description
    (MP9446) Alpha 1 Antitrypsin Inhibitors require prior authorization and is considered medically appropriate when the criteria listed in the medical policy are met.
    Last Updated
    6/14/2016
  • /app/files/public/3619/pdf-providers-Ambrisentan_LETAIRIS_9885.pdf Ambrisentan (LETAIRIS) Show Details
    Description
    Ambrisentan (LETAIRIS) PA9885 is an endothelin receptor antagonist for pulmonary arterial hypertension (PAH). (Related: right heart catheterization)
    Last Updated
    9/23/2015
  • /app/files/public/3621/pdf-providers-Anakinra_KINERET_9800.pdf Anakinra (KINERET) Show Details
    Description
    Anakinra (KINERET) PA9800 is an interleukin-1 (IL-1) receptor antagonist. (Related: rheumatoid arthritis (RA), tumor necrosis factor (TNF) inhibitor, Stills Disease, methotrexate.)
    Last Updated
    9/23/2015
  • /app/files/public/3623/pdf-providers-Aprepitant_EMEND_9852.pdf Aprepitant (EMEND) Show Details
    Description
    Aprepitant (EMEND) PA9852 is used to prevent and control nausea and vomiting associated with chemotherapy or anesthesia. (Related: cancer, post-operative.)
    Last Updated
    9/23/2015
  • /app/files/public/7854/Aripiprazole-Abilfy-Maintena-MP9456.pdf Aripiprazole (ABILIFY MAINTENA) Show Details
    Description
    Aripiprazole (ABILIFY MAINTENA) MP9456 requires prior authorization. It used in the treatment of schizophrenia and new starts must be prescribed by a Psychiatrist.
    Last Updated
    6/14/2016
  • /app/files/public/3627/pdf-providers-Armodafanil_NUVIGIL_9876.pdf Armodafanil (NUVIGIL) Show Details
    Description
    Armodafanil (NUVIGIL) PA9876 is used for narcolepsy treatment. (Related: Attention Deficit Disorder (ADD), Multiple Sclerosis, Sleep Apnea, CPCP, Bipap.)
    Last Updated
    9/23/2015