AUTHORIZATION REQUIRED for ESRD-RELATED PRESCRIPTION DRUGS for MEDICARE MEMBERS Effective Jan

Posted on NaviNet Plan Central page 1-17-2014

ATTENTION PHYSICIANS WHO PRESCRIBE MEDICATIONS FOR DIALYSIS PATIENTS AUTHORIZATION REQUIRED FOR ESRD-RELATED PRESCRIPTION DRUGS FOR MEDICARE MEMBERS Effective Jan. 1, 2014, Highmark Freedom Blue PPO and Blue Rx PDP members with End Stage Renal Disease (ESRD) who are also receiving renal dialysis services for ESRD require prior authorization on seven categories of prescription drugs (listed below) that may be ESRD-related. This prior authorization requirement has been implemented to comply with a Centers for Medicare and Medicaid Services (CMS) requirement that Part D sponsors ensure they do not pay for drugs and biologics that are included in the Medicare Part B bundled payment to an ESRD dialysis facility (as specified in section 1881(b)(14) of the Social Security Act and in Federal regulations at Part 413). This change also ensures that these drugs are not incorrectly applied to the member's Part D prescription drug benefit. If you do not obtain prior authorization for these medications when they are used for dialysis-related reasons for a patient with ESRD, coverage for the member could be denied. Since ESRD requires ongoing treatment, prior authorization for these patients can be obtained for up to one year. HOW TO REQUEST AUTHORIZATIONS FOR DRUGS ASSOCIATED WITH ESRD DIALYSIS TREATMENT If you are prescribing drugs in the categories listed below for dialysis-related reasons for a patient with ESRD, you need to request prior authorization from Highmark using the NaviNet Selection Form. The NaviNet Selection Form is the easiest, fastest and most accurate way to submit prescription authorization requests to Highmark. On this form, use the Comments section to indicate the diagnosis information and that the drug is being used in association with treatment for ESRD. For providers who wish to fax requests, a Medication Request Form (MM-056) is also available in the Provider Forms section on the Resource Center. You'll find it under Miscellaneous Forms. On this form, under Medical Rationale, indicate that the drug is being used in association with treatment for ESRD. Note: When used for treatment of conditions other than dialysis, the drugs in the following list can be covered under the member's Part D benefit. Drug Category Description Antiemetic Drugs used to prevent or treat nausea and vomiting secondary to dialysis, excluding antiemetics used in conjunction with chemotherapy as these are covered under a separate benefit category. Anti-infectives Drugs used to treat infections. These may include antibacterial and antifungal drugs. Antipruritic Drugs in this category have multiple clinical indications, but are included for their action to treat itching secondary to dialysis. Anxiolytic Drugs in this category have multiple actions, but are included for the treatment of restless leg syndrome secondary to dialysis. Excess fluid management Drugs/fluids used to treat fluid excess/overload. Fluid and electrolyte management including volume Intravenous drugs/fluids used to treat fluid and expanders electrolyte needs. Pain management Drugs used to treat graft site pain and to treat pain medication overdose. Continue to the following pages for a complete list of the drugs in these categories.

Drugs That May Be Used in Association with Dialysis for ESRD CYMBALTA HALOG KENALOG AZACTAM-ISO-OSMOTIC DEXTROSE AZACTAM NAPROSYN ROCEPHIN ANAPROX ANAPROX DS EC-NAPROSYN EMEND NOROXIN CLINORIL PRIMAXIN CANCIDAS INVANZ REQUIP XL REQUIP ALTABAX WYGESIC TRECATOR TYGACIL XANAX XANAX XR CLEOCIN HCL BACITRACIN ANSAID LINCOCIN CLEOCIN PHOSPHATE CLEOCIN PALMITATE CLEOCIN T CLEOCIN PHOSPHATE IN D5W ZYVOX AZULFIDINE MYCOBUTIN DEMEROL XYZAL DAYPRO ARTHROTEC CELEBREX FLAGYL FLAGYL ER BACTROBAN AMOXIL AUGMENTIN AUGMENTIN XR TIMENTIN RYNA-12 S RYNA-12 RYNATAN RYNATAN PEDIATRIC CESAMET DEMADEX ONSOLIS CLAFORAN LASIX TYLENOL W/CODEINE UNASYN ERAXIS(WATER DILUENT) PFIZERPEN ANTIVERT VFEND VFEND IV DIFLUCAN IN SALINE DIFLUCAN DIFLUCAN IN DEXTROSE MARINOL ALBUMINAR FLUCONAZOLE CLARITHROMYCIN ONDANSETRON HCL TORSEMIDE CALCIUM ACETATE ROPINIROLE HCL GRANISETRON HCL BUPRENORPHINE HYDROCHLORIDE MELOXICAM MORPHINE SULFATE CODEINE SULFATE HYDROMORPHONE HCL OXYMORPHONE HCL TINIDAZOLE METHADONE HCL LEVORPHANOL TARTRATE OXYCODONE HCL OXYCODONE W/ACETAMINOPHEN ALPRAZOLAM INTENSOL BUTORPHANOL TARTRATE DIAZEPAM FUROSEMIDE LIDOCAINE HCL LORAZEPAM INTENSOL MEPERIDINE HCL NAPROXEN ROXICET ROXANOL CLOTRIMAZOLE DOLOPHINE HCL DISKETS GRIFULVIN V ULTRAM ER ERTACZO PRUDOXIN DERMATOP BENZAMYCIN BENZAMYCINPAK PENLAC TRANSDERM-SCOP VOLTAREN RIFADIN RIFAMATE CEFOTAXIME SODIUM ETOMIDATE CEFTAZIDIME AMPICILLIN SODIUM FLUCONAZOLE IN SALINE TOBRAMYCIN SULFATE DOXYCYCLINE HYCLATE RIFAMPIN CEFAZOLIN SODIUM VIBRAMYCIN ZITHROMAX FELDENE ZMAX CEFTRIAXONE VISTARIL NEURONTIN LYRICA ULTRAVATE EXELDERM CODEINE PHOSPHATE NALOXONE HCL SODIUM CHLORIDE DEXTROSE IN WATER POTASSIUM CHLORIDE DEXTRAN 70 IN DEXTROSE 5% LORAZEPAM VICODIN AMIKACIN SULFATE VICODIN ES KETOROLAC TROMETHAMINE VICODIN HP VICOPROFEN BIAXIN ERYTHROMYCIN ETHYLSUCCINATE BIAXIN XL PCE MAGNESIUM SULFATE E.E.S. TPN ELECTROLYTES ERYTHROMYCIN ERYPED ERY-TAB ERYTHROCIN STEARATE HETASTARCH W/SODIUM CHLORIDE K-TAB INPERSOL W/DEXTROSE DEXTRAN IN DEXTROSE BUPIVACAINE HCL-EPINEPHRINE LAMISIL CATAFLAM VOLTAREN-XR TOBI TOBI PODHALER ELOCON DIPROLENE AF DIPROLENE LOTRISONE CLARINEX NOXAFIL AVELOX AVELOX ABC PACK AVELOX IV CIPRO CIPRO I.V. CIPRO XR RIFATER ALLEGRA RX ALLEGRA ODT RX ANZEMET PRIFTIN KETEK NIRAVAM ACETAMINOPHEN W/CODEINE BUSPIRONE HCL TRAMADOL HCL FLUOCINONIDE FLUOCINONIDE-E BETAMETHASONE DIPROPIONATE CLEMASTINE FUMARATE PROPOXYPHENE NAPSYLATE W/APAP NAPROXEN SODIUM BETA-VAL FLURBIPROFEN PROPOXYPHENE HCL DIFLUNISAL PIROXICAM KETOCONAZOLE ETODOLAC OXAPROZIN DICLOFENAC POTASSIUM NYSTATIN MUPIROCIN NABUMETONE GABAPENTIN DICLOFENAC SODIUM CEFPROZIL CEFACLOR ER PENICILLIN V POTASSIUM NEOMYCIN SULFATE AZITHROMYCIN TOLMETIN SODIUM HYDROCHLOROTHIAZIDE NITROFURANTOIN TRIMETHOPRIM METOCLOPRAMIDE HCL CEPHALEXIN AMOXICILLIN AMOX TR/POTASSIUM CLAVULANATE CYPROHEPTADINE HCL DICLOXACILLIN SODIUM CEFDINIR MINOCYCLINE HCL CLINDAMYCIN HCL KETOPROFEN CEFADROXIL INDOMETHACIN BUMETANIDE HYDROXYZINE HCL HYDROCODONE BIT-IBUPROFEN VORICONAZOLE FENTANYL CITRATE ALPRAZOLAM ER CETIRIZINE HCL FENTANYL GRISEOFULVIN OFLOXACIN CLARITHROMYCIN ER FEXOFENADINE HCL LEVOFLOXACIN HEMIHYDRATE TERBINAFINE ONDANSETRON ODT LEVOCETIRIZINE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL DOXEPIN HCL PROCHLORPERAZINE MALEATE CORMAX LODRANE ZOLVIT LODRANE 24D LODRANE D PROMETHAZINE HCL DOXYCYCLINE MONOHYDRATE LIDOCAINE-PRILOCAINE MOMETASONE FUROATE FLUTICASONE PROPIONATE DEMECLOCYCLINE HCL DIPHENHYDRAMINE HCL HYDROCODONE W/ACETAMINOPHEN IBUPROFEN SULFAMETHOXAZOLE/TRIMETHOPRIM CO-GESIC VALIUM CHLOROTHIAZIDE ISONIAZID BUTALBITAL-ASP-CAFFEINE CIPROFLOXACIN HCL BUTALBITAL/CAFF/APAP/CODEINE FLUCONAZOLE IN DEXTROSE LEVOFLOXACIN-D5W ONDANSETRON HCL IN DEXTROSE METRONIDAZOLE CEFOXITIN CEFUROXIME SODIUM CEFACLOR VUSION LUXIQ EVOCLIN OLUX-OLUX-E CLINDETS MACRODANTIN MACROBID TRIAMCINOLONE ACETONIDE HYDROCORTISONE BETAMETHASONE VALERATE FLUOCINOLONE ACETONIDE GENTAMICIN SULFATE NYSTATIN W/TRIAMCINOLONE DESOXIMETASONE CLOBETASOL PROPIONATE CLINDAMYCIN PHOSPHATE LIDOCAINE DIFLORASONE DIACETATE CLOTRIMAZOLE/BETAMETHASONE ALCLOMETASONE DIPROPIONATE AMCINONIDE DESONIDE ECONAZOLE NITRATE CICLOPIROX HALOBETASOL PROPIONATE PREDNICARBATE LIDOCAINE-HC TETRACYCLINE HCL OXAZEPAM TRAMADOL HCL-ACETAMINOPHEN ZINACEF TEMOVATE FORTAZ CEFTIN ACLOVATE FORTAZ IN ISO-OSMOTIC DEXTROSE ZINACEF ISO-OSMOTIC DEXTROSE ZINACEF IN ISO-OSMOTIC WATER EMGEL ZOFRAN MEPRON ZOFRAN ODT HORIZANT TEXACORT TINDAMAX NALTREXONE HYDROCHLORIDE METOLAZONE NITROFURANTOIN MACROCRYSTAL ITRACONAZOLE HYDROXYZINE PAMOATE CARISOPRODOL COMPOUND/CODEINE SULFADIAZINE XYLOCAINE WITH EPINEPHRINE XYLOCAINE VIMOVO NAROPIN NESACAINE-MPF SENSORCAINE ASTRAMORPH-PF CAPITAL W/CODEINE DIASTAT ACUDIAL ANCOBON ZOSYN BUTALBITAL COMPOUND ALPRAZOLAM INDAPAMIDE BUPRENORPHINE-NALOXONE OXYMORPHONE HCL ER MORPHINE SULFATE ER OXYCODONE HCL-IBUPROFEN KLOR-CON KLOR-CON-EF KLOR-CON M ZINC SULFATE TRIANEX NAFTIN ONMEL AQUA GLYCOLIC HC HYPERLYTE CR HESPAN RINGERS LACTATED RINGERS RESECTISOL CEFOTETAN & DEXTROSE CEFEPIME-DEXTROSE METRO IV GENTAMICIN SULFATE IN NS MANNITOL DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 10%-0.2% NACL POTASSIUM CHLORIDE/DEXTROSE POT CHLORIDE/DEXTROSE/NS ISOLYTE S ISOLYTE H WITH DEXTROSE ISOLYTE M WITH DEXTROSE ISOLYTE P WITH DEXTROSE DEXTROSE IN LACTATED RINGERS DEXTROSE IN RINGERS INJECTION POTASSIUM CHL-NORMAL SALINE DALLERGY-JR KAON-CL ORACEA CLOBEX CLINDAGEL CAPEX SHAMPOO DESOWEN PLIAGLIS MERREM ALA-QUIN ALA-CORT ALA-SCALP HP TRIDERM SODIUM LACTATE DEXTROSE-ELECTROLYTE PLASMA-LYTE 56 IN DEXTROSE PLASMA-LYTE 148 TIS-U-SOL PLASMA-LYTE A PH 7.4 OSMITROL POTASSIUM CHLORIDE-DW5-LR DEXTROSE-LACT RINGERS-KCL CIPROFLOXACIN-D5W OXACILLIN SODIUM NAFCILL IN DEXTROSE PENICILLIN GK-ISO-OSM DEXTROSE CEFEPIME HCL ONDANSETRON IN SODIUM CHLORIDE CLORAZEPATE DIPOTASSIUM PROPOXYPHENE HCL W/APAP METHYCLOTHIAZIDE CHLORTHALIDONE SULINDAC FENOPROFEN CALCIUM CIPROFLOXACIN ER MECLOFENAMATE SODIUM DESLORATADINE MECLIZINE HCL OXYCODONE W/ASPIRIN MENTAX DRONABINOL ETHYL CHLORIDE SPRAY AND STRETCH PAIN EASE DEPADE METHADOSE MAXIPIME LIDOCAINE HCL W/EPINEPHRINE VOLUVEN CARBOCAINE BUPIVACAINE HCL DROPERIDOL NALBUPHINE HCL HEXTEND LACTATED ELECTROLYTE MARCAINE MARCAINE WITH EPINEPHRINE MARCAINE SPINAL PONTOCAINE TALWIN TRIMETHOBENZAMIDE HCL KETAMINE HCL ALFENTANIL HYDROCHLORIDE MIDAZOLAM HCL AMPICILLIN/SULBACTAM POTASSIUM ACETATE SODIUM ACETATE PENTOTHAL PIPERACILLIN-TAZOBACTAM SUFENTANIL CITRATE TOBRAMYCIN SULFATE IN NS MEROPENEM IMIPENEM-CILASTATIN SODIUM BUPIVACAINE W/DEXTROSE ZINC CHLORIDE CHLOROPROCAINE HCL POTASSIUM PHOSPHATE PRE-ATTACHED LTA KIT PROPOFOL LIDOCAINE HCL IN 7.5% DEXTROSE CIPROFLOXACIN DEXTROSE 10%-1/4NS SODIUM BICARBONATE TAZICEF AMMONIUM CHLORIDE MORPHINE SULFATE IN DEXTROSE ERYTHROCIN LACTOBIONATE NEUT AMIDATE MAGNESIUM SULFATE IN DEXTROSE IONOSOL B WITH DEXTROSE 5% IONOSOL MB W/DEXTROSE SODIUM PHOSPHATE LMD 10% WITH 5% DEXTROSE LMD 10% WITH 0.9% SODCHLORIDE MEPIVACAINE HCL NORMOSOL-R PH 7.4 NORMOSOL-M AND DEXTROSE NORMOSOL-R NORMOSOL-R AND DEXTROSE DORYX AMPICILLIN TRIHYDRATE BUTALBITAL COMPOUND W/CODEINE CEFUROXIME AXETIL CHLORDIAZEPOXIDE HCL LEVAQUIN SALSALATE TEFLARO PANDEL CUTIVATE OXISTAT APEXICON APEXICON E AMBISOME MYCAMINE PROMETHAZINE 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