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Drug Policies

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Documents for Drug Policies

  • /app/files/public/7854/Aripiprazole-Abilfy-Maintena-MP9456.pdf ABILIFY MAINTENA (aripiprazole) Show Details
    Description
    ABILIFY MAINTENA (aripiprazole) MP9456 requires prior authorization. It used in the treatment of schizophrenia and new starts must be prescribed by a Psychiatrist.
    Last Updated
    10/11/2016
  • /app/files/public/4766/pdf-medicalpolicies-9405Tocilizumab.pdf ACTEMRA (tocilizumab) IV Show Details
    Description
    ACTEMRA (tocilizumab) IV (MP9405) requires prior authorization and is considered medically appropriate for: Adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response TNF antagonist therapies.
    Last Updated
    10/12/2016
  • /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/9418/ALECENSA-alectinib-PA9924.pdf ALECENSA (alectinib) PA9924 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
    10/3/2016
  • /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/3671/pdf-providers-DarbepoetinAlpha_ARANESP_9799.pdf ARANESP (darbepoetin alpha) Show Details
    Description
    ARANESP (darbepoetin alpha) (PA9799) Increases red blood cell count. (Related: renal failure, anemia, HIV, aplastic, hepatitis C, chemotherapy.)
    Last Updated
    10/10/2016
  • /app/files/public/4781/pdf-medicalpolicies-9431Avastin.pdf AVASTIN (bevacizumab) Show Details
    Description
    AVASTIN (bevacizumab) 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
    10/11/2016
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