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Drug Prior Authorization List

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Drug Prior Authorization List Drug Prior Authorization List Why do some drugs require prior authorization? Prior authorization is a tool to ensure the appropriate use of certain drugs and allows us to determine if a drug meets the medical necessity requirements of your policy. Who makes the prior authorization decisions? Physicians and pharmacists at your health plan or at one of our partners, Diplomat or Express Scripts. The list to follow specifies who performs the review and makes the decision. Why am I sometimes asked to use a different drug than my doctor prescribed? If you go to the pharmacy to have your prescription filled before getting prior authorization when required, your pharmacist may tell you about other medications that may be equally effective but don’t require prior authorization. If this occurs, contact your doctor to ask about changing the prescription to the other drug. If your doctor approves, the pharmacy can immediately fill the prescription. What information is used by the physician or pharmacist in the decision-making process? Medical records describing the patient’s condition and prior treatments, FDA approved labeling for the requested treatment, published and peer-reviewed scientific literature, and/or evidence-based guidelines. Where can I view or obtain a copy of the prior authorization or step therapy criteria? l For drugs reviewed by Diplomat, you can call 1-888-515-1357 or access the current prior authorization criteria online at www.diplomatpharmacy.com/criteria. l For drugs reviewed by Express Scripts, please call 1-800-753-2851 to speak with a prior authorization specialist for more detailed information. Notes for reading the information on the following pages: * Brand Names and Codes are provided for information only. ǂ Vivio does not review requests for Aspirus Arise members. § Diplomat reviews requests for all Aspirus Arise members. ** "NPF Excl" indicates drugs that are on the ESI NPF Exclusion List and may require a trial of an alternative drug prior to approval. Page | 1 31852-080-2012 Revised: December 2020 Diplomat Review Express Scripts WPS ': 1-888-515-1357 7: 1-844-262-8479 Review Review OR ': 1-800- ': 1-800-753-2851 Vivio Review (WPS Employees Only) 333-5003 7: 1-877-329-3760 ': 1-925-365-6600 7: 1-888-677-6754 Aspirus Arise M= Medical vs. Directed to Home Express & Arise § Review P= Pharmacy Diplomat or Self Scripts Step ': 1-888- GENERIC NAME BRAND NAME* CODE* Benefit Review Administration Review** Therapy 711-1444 Paclitaxel, Protein Bound ABRAXANE J9264 M X Ferric maltol ACCRUFER J8499 P X Tocizilumab ACTEMRA J3262 P X Corticotropin ACTHAR GEL J0800 M X Interferon gamma-1b ACTIMMUNE J9216 P X Pegademase ADAGEN J2504 M X Crizanlizumab - tmca ADAKVEO C9053 M X Brentuximab ADCETRIS J9042 M X Tadalafil ADCIRCA J8499 P X Riociguat ADEMPAS J8499 P X Doxorubicin ADRIAMYCIN J9000 M X Anti-Hemophilic Factor ADVATE J7192 M X X Factor VIII pegylated ADYNOVATE J7192 J7207 M X X Everolimus AFINITOR J8999 P X Everolimus AFINITOR DISPERZ J8999 P X Factor VIII AFSTYLA J7210 C9140 M X X Netupitant/Palonosetron AKYNZEO C9448 P X Fosnetupitant/Palonosetron AKYNZEO INJ J1454 M X Laronidase ALDURAZYME J1931 M X X Alectinib ALECENSA J8999 P X Pemetrexed ALIMTA J9305 M X Copanlisib ALIQOPA J9057 C9030 M X Melphalan ALKERAN INJECTION J9245 M X Melphalan ALKERAN TABLET J8999 P X Palonosetron ALOXI J2469 M X Anti-Hemophilic Factor ALPHANATE J7186 M X X Anti-Hemophilic Factor ALPHANINE SD J7193 M X X Coagulation Factor IX ALPROLIX C9135 J7201 M X X Brigatinib ALUNBRIG J8999 P X Tadalafil ALYQ J8499 P X Amifostine AMIFOSTINE J0207 M X Page | 2 Revised: December 2020 Diplomat Review Express Scripts WPS ': 1-888-515-1357 7: 1-844-262-8479 Review Review OR ': 1-800- ': 1-800-753-2851 Vivio Review (WPS Employees Only) 333-5003 7: 1-877-329-3760 ': 1-925-365-6600 7: 1-888-677-6754 Aspirus Arise M= Medical vs. Directed to Home Express & Arise § Review P= Pharmacy Diplomat or Self Scripts Step ': 1-888- GENERIC NAME BRAND NAME* CODE* Benefit Review Administration Review** Therapy 711-1444 Dalfampridine AMPYRA J8499 P X Dolasetron mesylate (inj) ANZEMET J1260 M X Apomorphine APOKYN J0364 P X Alpha Proteinase Inhibitor ARALAST J0256 M X X Darbepoetin ARANESP J0881 J0882 P X X (non-dialysis) Rilonacept ARCALYST J2793 P X Amikacin liposomal ARIKAYCE J3490 M X Nelarabine ARRANON J9261 M X Ofatumumab ARZERRA J9302 M X Calaspargase pegol-mknl ASPARLAS J9118 M X Antithymocyte globulin ATGAM J7504 M X Teriflunomide AUBAGIO J8499 P X Deutetrabenazine AUSTEDO J8499 P X Anti-Inhibitor Coagulant AUTOPLEX-T J7198 M X X Bevacizumab AVASTIN J9035 M X Interferon beta-1a AVONEX J1826 P X Azacitidine AZACITIDINE J9025 M X Iobenguane Iodine-131 AZEDRA A9508 M X Erdafitinib BALVERSA J9999 P X Entecavir BARACLUDE J8499 P X Avelumab BAVENCIO J9023 C9491 M X BCG LIVE INTRAVESICAL BCG live intravesical vaccine J9030 J9031 M X VACCINE Prothrombin complex BEBULIN J7194 M X X Belinostat BELEODAQ C9442 J9032 M X Bendamustine Hydrochloride BELRAPZO J9036 M X Bendamustine BENDEKA J9033 J9034 M X Coagulation Factor IX BENEFIX J7195 M X X Belimumab BENLYSTA J0490 M X Brolucizumab–dbll BEOVU J0179 M X Page | 3 Revised: December 2020 Diplomat Review Express Scripts WPS ': 1-888-515-1357 7: 1-844-262-8479 Review Review OR ': 1-800- ': 1-800-753-2851 Vivio Review (WPS Employees Only) 333-5003 7: 1-877-329-3760 ': 1-925-365-6600 7: 1-888-677-6754 Aspirus Arise M= Medical vs. Directed to Home Express & Arise § Review P= Pharmacy Diplomat or Self Scripts Step ': 1-888- GENERIC NAME BRAND NAME* CODE* Benefit Review Administration Review** Therapy 711-1444 C1-esterase inhibitor BERINERT J0597 M X X Inotuzumab ozogamicin BESPONSA j9299 M X Interferon beta-1b BETASERON J1830 P X Tobramycin inhalation BETHKIS J3490 P X Bevacizumab BEVACIZUMAB J9035 C9257 M X Tositumomab BEXXAR A9545 M X Carmustine BICNU J9050 M X Anti-Hemophilic Factor BIOCLATE J7192 M X X Immune Globulin BIVIGAM J1556 M X X Belantamab mafodotin-blmf BLENREP J8999 M X Bleomycin BLEO 15K J9040 M X Blinatumomab BLINCYTO J9039 M X Ibandronate BONIVA INJECTION J1740 M X Bortezomib BORTEZOMIB J9041 M X Bosutinib BOSULIF J8999 P X Botulinum Toxin BOTOX J0585 M X Encorafenib BRAFTOVI J8999 P X Cerliponase alfa BRINEURA J0567 C9014 M X Zanubrutinib BRUKINSA J8999 P X Busulfan BUSULFEX J0594 J8510 M X Caplacizumab-yhdp CABLIVI J3590 M X Cabozantinib CABOMETYX J8999 P X Acalabrutinib CALQUENCE J8999 P X J0202 J9010 Alemtuzumab CAMPATH M X Q9979 Irinotecan CAMPTOSAR J9206 M X Capecitabine CAPECITABINE J8520 J8521 P X Vandetanib CAPRELSA J8999 P X Carglumic Acid CARBAGLU J8499 P X Immune Globulin - Intravenous CARIMUNE J1556 M X X (IVIG) Page | 4 Revised: December 2020 Diplomat Review Express Scripts WPS ': 1-888-515-1357 7: 1-844-262-8479 Review Review OR ': 1-800- ': 1-800-753-2851 Vivio Review (WPS Employees Only) 333-5003 7: 1-877-329-3760 ': 1-925-365-6600 7: 1-888-677-6754 Aspirus Arise M= Medical vs. Directed to Home Express & Arise § Review P= Pharmacy Diplomat or Self Scripts Step ': 1-888- GENERIC NAME BRAND NAME* CODE* Benefit Review Administration Review** Therapy 711-1444 Aztreonam CAYSTON J3490 P X Lomustine CEENU J8999 P X Protein C CEPROTIN J2724 M X Eliglustat CERDELGA J8499 P X X Alglucerase CEREDASE J0205 M X Imiglucerase CEREZYME J1786 M X X Daunorubicin CERUBIDINE J9151 M X Nabilone CESAMET J8499 P X Chenodeoxycholic acid CHENODAL J8499 P X Certolizumab CIMZIA J0717 P X Reslizumab CINQAIR J2786 M X C1-esterase inhibitor CINRYZE J0598 M X Aprepitant CINVANTI C9463 J0185 M X Clofarabine CLOFARABINE J9027 M X Clofarabine CLOLAR J9027 M X Trientine CLOVIQUE J8499 P X Factor X COAGADEX J7175 J7199 M X X Cabozantinib COMETRIQ J8999 P X Glatiramer Acetate COPAXONE J3490 P X Ribavirin COPEGUS J8499 P X Duvelisib COPIKTRA J8999 P X J7190 J7191 Factor VIII Concentrate CORIFACT M X X J7192 Secukinumab COSENTYX C9399 P X Dactinomycin COSMEGEN J9120 M X Cobimetinib COTELLIC J8999 P X Burosumab-twza CRYSVITA J0584 M X Immune Globulin - Subcutaneous CUVITRU J1555 M X X (SC) Ramucirumab CYRAMZA C9025 J9308 M X Betaine CYSTADANE J8499 P X Page | 5 Revised: December 2020 Diplomat Review Express Scripts WPS ': 1-888-515-1357 7: 1-844-262-8479 Review Review OR ': 1-800- ': 1-800-753-2851 Vivio Review (WPS Employees Only) 333-5003 7: 1-877-329-3760 ': 1-925-365-6600 7: 1-888-677-6754 Aspirus Arise M= Medical vs. Directed to Home Express & Arise § Review P= Pharmacy Diplomat or Self Scripts Step ': 1-888- GENERIC NAME BRAND NAME* CODE* Benefit Review Administration Review** Therapy 711-1444 Cysteamine CYSTAGON J8499 P X Cysteamine CYSTARAN J8499 P X Cytarabine CYTARABINE J9100 M X Cytomegalovirus Immune CYTOGAM J0850 P X Globulin Decitabine DACOGEN J0894 M X Dactinomycin DACTINOMYCIN J9120 M X Daclatasvir DAKLINZA J8499 P X Pyrimethamine DARAPRIM J8499 P X Daratumumab DARZALEX J9145 M X Daratumumab and Hyalurinidase DARZALEX FASPRO C9062 M X Daunorubicin liposome DAUNOXOME J9151 M X Glasdegib DAURISMO J8999 P X Desmopressin Acetate DDAVP J8499 P X Cytarabine liposome DEPOCYT J9098 M X Desmopressin Acetate DESMOPRESSIN ACETATE J8499 P X Stiripentol DIACOMIT J8499 P X Phenoxybenzamine hydrochloride DIBENZYLINE J8499 P X Docetaxel DOCEFREZ J9170 M X Docetaxel DOCETAXEL J9170 J9171 M X Triheptanoin DOJOLVI J8499 P X Avatrombopag DOPTELET J8499 P X J9002 Q2049 Doxorubicin liposomal DOXIL M X Q2050 DOXORUBICIN J9002 Q2049 Doxorubicin liposomal M X LIPOSOMAL Q2050 Dacarbazine DTIC-DOME J9130 M X Dupilumab DUPIXENT J3590 P X Bimatoprost Implant DURYSTA J7351 M X Page | 6 Revised: December 2020 Diplomat Review Express Scripts WPS ': 1-888-515-1357 7: 1-844-262-8479 Review Review OR ': 1-800- ': 1-800-753-2851 Vivio Review (WPS Employees Only) 333-5003 7: 1-877-329-3760 ': 1-925-365-6600 7: 1-888-677-6754 Aspirus Arise M= Medical vs.
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