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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 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
    2/13/2014
  • /app/files/public/3611/pdf-providers-Adalimumab_HUMIRA_9822.pdf Adalimumab 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
    2/13/2014
  • /app/files/public/4690/pdf-medicalpolicies-9300Agalsidase.pdf Agalsidase (Fabrazyme) for Treatment of Fabry’s Disease Show Details
    Description
    MP9300 (Fabrazyme) Agalsidase 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
    2/13/2014
  • /app/files/public/3617/pdf-providers-Almotriptan_AXERT_9892.pdf Almotriptan (AXERT) Show Details
    Description
    (PA9892) A 5-HT receptor agonist, indicated for the acute treatment of migraine headache.
    Last Updated
    2/13/2014
  • /app/files/public/3619/pdf-providers-Ambrisentan_LETAIRIS_9885.pdf Ambrisentan (LETAIRIS) Show Details
    Description
    (PA9885) Letairis is an endothelin receptor antagonist for pulmonary arterial hypertension (PAH). (Related: right heart catheterization)
    Last Updated
    2/13/2014
  • /app/files/public/3621/pdf-providers-Anakinra_KINERET_9800.pdf Anakinra (KINERET) Show Details
    Description
    (PA9800) An interleukin-1 (IL-1) receptor antagonist. (Related: rheumatoid arthritis (RA), tumor necrosis factor (TNF) inhibitor, Stills Disease, methotrexate.)
    Last Updated
    2/13/2014
  • /app/files/public/3623/pdf-providers-Aprepitant_EMEND_9852.pdf Aprepitant (EMEND) Show Details
    Description
    (PA9852) To prevent and control nausea and vomiting associated with chemotherapy or anesthesia. (Related: cancer, post-operative.)
    Last Updated
    2/13/2014
  • /app/files/public/3625/pdf-providers-Aripiprazole_ABILIFY_9829.pdf Aripiprazole (ABILIFY) Show Details
    Description
    (PA9829) Abilify is an antipsychotic medication. Prior Authorization is required for all clinicians. (Related: schizophrenia, bipolar, manic depression, autistic disorder.)
    Last Updated
    2/13/2014
  • /app/files/public/3627/pdf-providers-Armodafanil_NUVIGIL_9876.pdf Armodafanil (NUVIGIL) Show Details
    Description
    (PA9876) Narcolepsy treatment. (Related: Attention Deficit Disorder (ADD), Multiple Sclerosis, Sleep Apnea, CPCP, Bipap.)
    Last Updated
    2/13/2014
  • /app/files/public/4781/pdf-medicalpolicies-9431Avastin.pdf Bevacizumab (Avastin) for Cancer Treatment 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
    2/13/2014