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Drug Policies

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Documents for Drug Policies

  • /app/files/public/4783/pdf-medicalpolicies-Abatacept_ORENCIA_9846.pdf Abatacept (ORENCIA) 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
    9/22/2015
  • /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
    9/23/2015
  • /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
    3/2/2015
  • /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
  • /app/files/public/4781/pdf-medicalpolicies-9431Avastin.pdf Bevacizumab (AVASTIN) Show Details
    Description
    Bevacizumab (AVASTIN) MP9431 is considered medically appropriate when the listed criteria are met for any one of the following diagnosis: metastatic colorectal cancer, non-squamous non-small cell lung cancer (NSCLC), glioblastoma or metastatic renal cell carcinoma.
    Last Updated
    9/22/2015
  • /app/files/public/3638/pdf-providers-Bexarotene_TARGRETIN_9857.pdf Bexarotene (TARGRETIN) Show Details
    Description
    Bexarotene (TARGRETIN) (PA9857) capsules requires prior authorization and is considered medically appropriate when criteria are met. (Related: cutaneous T-cell lymphoma (CTCL), systemic therapy, lesions.)
    Last Updated
    9/29/2015