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Prior Authorization and Investigational Services List Pr ior Authorization and Investigational Services List Services Requiring Prior Authorization (Revised August 2021) Please note: The terms prior authorization, prior approval, predetermination, advance notice, precertification, preauthorization and prior notification all refer to the same process. SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Care Management Web: http://navinet.force.com Ambulance Services Non-emergency air ambulance transportation All contracted providers need to submit via the web. Only non-contracted providers can submit via fax. Abdominoplasty/Panniculectomy Blepharoplasty, Brow Lift and Blepharoptosis Repair Care Management Breast Reconstruction and Related Procedures Web: http://navinet.force.com Laser Therapy for Treatment of Rosacea Or Mastectomy (Bilateral Prophylactic) Fax: 1-877-321-6664 Cosmetic/Reconstructive Mastopexy Prior Approval Form Procedures* Otoplasty Reduction Mammoplasty All contracted providers need Rhinoplasty to submit via the web. Only Septoplasty non-contracted providers can Surgical Repair of Pectus Deformities submit via fax. Surgical Treatment of Gynecomastia Air Fluidized Bed New requirement! Prior approval required effective 7/1/2020 Bone Growth Stimulation: Electrical and Ultrasonic Continuous Glucose Monitoring Systems Cranial Orthosis for Plagiocephaly DME Misc. Items >$1,000 Care Management Functional Electrical Stimulation Web: http://navinet.force.com High Frequency Chest Wall Oscillation System Or Durable Medical INR Monitoring System Fax: 1-877-321-6664 Equipment Knee Braces (Custom Fabricated) Prior Approval Form (DME)/Prosthetics/ Mechanical Insufflation-Exsufflation Therapy Orthotics* Motorized Wheelchairs, Power Accessories and Power All contracted providers need Operated Vehicles to submit via the web. Only Pneumatic Compression Device non-contracted providers can Pressure Reducing Support Surfaces submit via fax. Prosthetics (microprocessor systems) Pulse Oximeter (home use) Speech-Generating Devices Tumor Treating (Treatment) Fields for Glioblastoma Multiforme Wearable Cardioverter Defibrillator (WED) X9158-CMT R8/21 (Revised August 2021) Page 1 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) * All Genetic Testing, Gene Expression Testing and Microarray Analysis testing requires prior authorization (unless specified as not required). Prior to testing for hereditary conditions Genetic Counseling is required. Care Management Web: http://navinet.force.com Breast Cancer Susceptibility 1 (BRCA1) Or Breast Cancer Susceptibility 2 (BRCA2) Fax: 1-877-321-6664 Genetic Testing/Gene Breast Cancer Susceptibility 1 and 2 Large Rearrangement Prior Approval Form Expression/Microarray Testing Analysis* All contracted providers need Chromosomal Microarray Analysis to submit via the web. Only Gene Expression Assays for the Management of Breast non-contracted providers can Cancer submit via fax. Genetic Testing for Colorectal Cancer Susceptibility Genetic Testing for Inherited Disorders Surrogate Markers for Detection of Heart Transplant Rejection – Gene Expression Profiling (e.g., AlloMap) Abatacept (Orencia IV and SC) Adalimumab (Humira) Adalimumab-afzb (Abrilada) Ado-trastuzumab emtansine (Kadcyla®) Aducanumab (AduhelmTM) [New PA requirement effective 7/30/2021] Afamelanotide (Scenesse) Aflibercept (Eylea®) Agalsidase beta (Fabrazyme®) Alemtuzumab (Lemtrada®) (when utilized for treatment of multiple sclerosis) Alglucosidase alfa (Lumizyme®, Myozyme®) Alirocumab (Praluent®) Alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®, Prolastin®-C, Zemaira™) Amivantamab-vmjw (RybrevantTM) [New PA requirement Medical Drug Management effective 8/13/2021] Web: ih.magellanrx.com Injectables* Anakinra (Kineret®) Fax: 1-888-656-1948 Anifrolumab-FNIA (SaphneloTM) [New PA requirement effective Phone: 1-800-424-7698 8/13/2021] Arsenic Trioxide (Trisenox) Prior Approval Form Asparaginase Erwinia chrysanthemi (Erwinaze) Asparaginase Erwinia chyrsanthemi (recombinant)-rwyn (RylazeTM) [New PA requirement effective 8/13/2021] Atezolizumab (Tecentriq®) Avalgucosidase alfa-ngpt (Nexviazyme TM) [New PA requirement effective 8/13/2021] Avelumab (Bavencio®) Axicabtagene ciloleucel (Yescarta®) Belantamab (Blenrep) Belimumab (Benlysta IV and SC) Bendamustine (Treanda, Belrapzo, Bendeka™) Benralizumab (Fasenra) Bevacizumab (Avastin, Bevacizumab-awwb (mvasi), Bevacizumab-bvzr (Zirabev) (prior approval is required for all conditions except diabetic macular edema, macular edema following retinal vein occlusion, or neovascular (wet) age- Revised August 2021 Page 2 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) related macular degeneration) Bivigam Blinatumomab (Blincyto®) Bortezomib (Velcade) Botulinum Toxin Type A and B Bremelanotide (Vyleesi) Brentuximab vedotin (Adcetris®) Brexucabtagene autoleucel (Tecartus) Brodalumab (Siliq ™) Brolucizumab-dbll (Beovu) Burosumab (Crysvita) Cabazitaxel (Jevtana) Cabotegravir/ rilpivirine (Cabenuva) [New PA requirement effective 2/1/2021] Calaspargase Pegol-mknl (Asparlas) Canakinumab (Ilaris®) Caplacizumab-yhdp (Cablivi) Carfilzomib (Kyprolis®) Casimersen (Amondys 45) [New PA requirement effective 3/1/2021] Cemiplimab-rwlc (Libtayo) Cerliponase alfa (Brineura®) Certolizumab pegol (Cimzia) Cetuximab (Erbitux®) C1 esterase inhibitor (Berinert) C1 esterase inhibitor (Cinryze) Medical Drug Management Injectables* C1 esterase inhibitor (Haegarda) Web: ih.magellanrx.com Copanlisib (Aliqopa®) Fax: 1-888-656-1948 Crisanlizumab-tmca (Adakveo) Phone: 1-800-424-7698 Cuvitru (immune globulin subcutaneous 20% solution) Prior Approval Form Daratumumab (Darzalex™) Daratumumab hyaluronidase-fihj (Darzalex Faspro) Darbepoetin alfa (Aranesp®) Daunorubicin/cytarabine (Vyxeos®) Denosumab (Xgeva®) Dostarlimab-gxly (Jemperli) [New PA requirement effective 5/1/2021] Dupilumab (Dupixent®) Durvalumab (Imfinzi®) Ecallantide (Kalbitor) Eculizumab (Soliris®) Edaravone(Radicava®) Elapegademase-lvlr (Revcovi™) Elosulfase alfa (Vimizim) Elotuzumab (Empliciti™) Emapalumab-lzsg (Gamifant) Emicizumab-kxwh (Hemlibra) Enfortumab vedotin-ejfv (Padcev) Enzyme Replacement Therapy for Gaucher Disease (imiglucerase, taliglucerase alfa, velaglucerase alfa) Epoprostenol (Flolan, Veletri) Eptinezumab-jjmr (Vyepti) Revised August 2021 Page 3 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Erenumab-aooe (Aimovig™) Eribulin mesylate (Halaven®) Erythropoietin alfa (Epogen®, Procrit®, Retacrit) Esketamine (Spravato™) Etanercept (Enbrel) Eteplirsen (Exondys51) Evinacumab-dgnb (Evkeeza) [New PA requirement effective 2/1/2021] Evolocumab (Repatha®) Filgrastim (Neupogen®) Filgrastim-aafi (Nivestym™) Fligrastim-sndz (Zarxio™) Flebogamma DIF Fosdenopterin (NulibryTM) [New PA requirement effective 4/1/2021] ™) Fremanezumab-vfrm (Ajovy Fulvestrant (Faslodex®) Galcanezumab-gnlm (Emgality™) Galsulfase (Naglazyme®) Gammagard (all forms) Gammaked Gammaplex Gamunex (all forms) Gemtuzumab Ozogamicin (Mylotarg®) Glatiramer acetate (Copaxone, Glatopa) Medical Drug Management New Drug Prior Approval Policy (Global Prior Approval) Web: ih.magellanrx.com Injectables* Givosiran (Givlaari) Fax: 1-888-656-1948 Golimumab (Simponi ARIA and SC) Phone: 1-800-424-7698 Golodirsen (Vyondys 53) Prior Approval Form Growth Stimulating Drugs Guselkumab (Tremfya) Hizentra Ibalizumab-uiyk (Trogarzo) Icatibant (Firazyr®) TM Idecabtagene vicleucel (Abecma ) [New PA requirement effective 5/1/2021] Idursulfase (Elaprase®) Iloprost (Ventavis) Immune globulins (administered intravenous and subcutaneous) Inebilizumab-cdon (Uplinza) Infliximab (Remicade) Infliximab-dyyb (Inflectra®) Infliximab-abda (Renflexis®) Infliximab-axxq (Avsola) Inotersen (Tegsedi) Inotuzumab Ozogamicin (Besponsa®) Interferon beta-1a (Avonex®, Plegridy™, Rebif®) Interferon beta-1b (Betaseron®, Extavia®) Ipilimumab (Yervoy®) Iobenguane I 131 (Azedra®) Irinotecan liposomal (Onivyde®) Revised August 2021 Page 4 of 11 SUBMIT TO CATEGORY DETAILS (PROVIDER USE ONLY) Isatuximab-irfc (Sarclissa) Ixabepilone (Ixempra®) Ixekizumab (Taltz®) Lanadelumab (Takhzyro®) Laronidase (Aldurazyme®) Levoleucovorin (Fusilev, Khapzory) [New PA requirement effective 1/1/2021] Lisocabtagene maraleucel (Breyanzi) [New PA requirement effective 2/1/2021} Loncastuximab tesirine-lpyl (Zynlonta) [New PA requirement effective 5/1/2021] Lumasiran (Oxlumo) [New PA requirement effective 12/1/2020] Lurbinectedin (Zepzelca) Luspatarcept-aamt (Reblozyl) Lutetium Lu 177 dotatate (Lutathera®) Melphalan flufenamide (Pepaxto) [New PA requirement effective 3/1/2021] Mepolizumab (Nucala®) Mitomycin (Jelmyto) Methoxy polyethylene glycol-epoetin beta (Mircera®) Mogamulizumab-kpkc (Poteligeo®) Moxetumomab pasudotox-tdfk (Lumoxiti) Natalizumab (Tysabri) Naxitamab-gpgk (Danyelza) [New PA requirement effective 12/1/2020] Medical Drug Management Necitumumab (Portrazza™) Web: ih.magellanrx.com Injectables* Nelarabine (Arranon) Fax: 1-888-656-1948 Nivolumab (Opdivo®) Phone: 1-800-424-7698 Nusinersen (Spinraza®) Prior Approval Form Obinutuzumab (Gazyva®) Ocrelizumab (Ocrevus®) Octagam Ofatumumab (Arzerra) Ofatumumab (Kesimpta) [New PA requirement effective 10/9/2020] Omacetaxine mepesuccinate (Synribo®) Omalizumab (Xolair®) Onasemnogene abeparvovec (Zolgensma®) Paclitaxel albumin-bound (Abraxane®) Panzyga (IVIG) Pain Management Medications Panitumumab (Vectibix®) Patisirin (Onpattro®) Pegaptanib sodium (Macugen®) Pegaspargase (Oncaspar) Pegcetacoplan (Empaveli) [New PA requirement effective 6/1/2021] Pegfilgrastim (Neulasta®) Pegfilgrastim-bmez (Ziextenzo) Pegfilgrastim-jmdb (Fulphila™) Pegfilgrastim-apgf (Nyvepria)
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