MedStar Select Pharmacy Services

Transcription

1 Pharmacy Services 1 MedStar Select Pharmacy Services Table of Contents At a Glance..page 2 Obtaining Prior Authorization for Medically Covered Medications..page 2

2 Pharmacy Services 2 At a Glance Welcome to MedStar Select Pharmacy Services. MedStar Select Pharmacy Services partners with CVS Caremark to meet the medication and cost needs of patients. For more information please contact Caremark: By Phone: (888) By Website: Click Here Please note, to request prior authorization for medications covered under the medical benefit, please call the MedStar Medical Prior Authorization Services Team at Obtaining Prior Authorization for Medically Covered Medications Medically covered medications are those medications (i.e. IV infusions) that will be administered by a health care provider. For Medications Covered under the Medical Benefit: To request Prior Authorization for medications covered under the medical benefit, please contact the Medically Covered Prior Authorization Team for assistance at Fax Instructions for Prior Authorization Forms: Completed forms should be faxed, along with supporting documentations to Pharmacy Services at Prior authorization forms can be found here. 1. Please indicate on the form that the request is going to be for the medical benefit 2. To avoid delays in responses, please provide all relevant information. Some examples include: a. Patient diagnosis b. Previously medications attempts (including the trial period) c. Supporting documentation d. Notes from patients most recent office visit e. Contact information for attending physician or office manager on the fax document 3. For additional support regarding J-Code selection for Medically Covered Medications provided under the medical benefit, please refer to the table provided below. Prior Authorization for Medical Necessity Pharmacy Review Process If the request is approved under the medical benefit, you will be provided with an authorization number to provide on your claim submittal via a faxed approval letter. If

3 Pharmacy Services 3 coverage is denied, you will be notified of the denial reason and the appeals process via fax to the office, and letter to the patient. **please note, the below list is subject to change** J-Code Brand Name Description Prior Authorization for Medical PA's apply at all places of service except 21 (inpatient) unless otherwise specified CM Effective Date (CPT) Synagis PALIVIZUMAB X 7/1/2011 C9026 Entyvio Injection, vedolizumab, 1 mg X 10/1/2014 J0129 Orencia INJECTION, ABATACEPT, 10 (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF- ADMINISTERED) J0135 Humira INJECTION, ADALIMUMAB, 20 J0178 Eylea Injection, aflibercept, 1 mg X 1/1/2013 J0180 Fabrazyme INJECTION, AGALSIDASE BETA, 1 J0220 Myozyme INJECTION, ALGLUCOSIDASE ALFA, 10, NOT OTHERWISE SPECIFIED J0221 Lumizyme Injection, alglucosidase alfa, J0256 J0257 Aralast NP, Prolastin, Prolastin C, Zemaira Glassia (Lumizyme), 10 mg INJECTION, ALPHA 1- PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg J0364 Apokyn INJECTION, APOMORPHINE HYDROCHLORIDE 1 J0401 Abilify Maintena Injection, aripiprazole, extended release, 1 mg J0485 Nulojix Injection, belatacept, 1 mg X 1/1/2013 J0490 Benlysta Injection, belimumab, 10 mg X 1/1/2012 J0585 Botox INJECTION, ONABOTULINUMTOXINA, 1 UNIT

4 Pharmacy Services 4 J0586 Dysport AbobotulinumtoxinA J0587 Myobloc INJECTION, RIMABOTULINUMTOXINB, 100 UNITS J0588 Xeomin Injection, incobotulinumtoxina, 1 unit J0597 Berinert INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), X 7/1/2011 BERINERT, 10 UNITS J0598 Cinryze INJECTION, C-1 ESTERASE, 10 UNITS J0638 Ilaris Canakinumab injection X 7/1/2011 J0717 Cimzia Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) J0718 Cimzia INJECTION, CERTOLIZUMAB PEGOL, 1 J0800 Acthar Gel Corticotropin injection X 7/1/2011 J0897 Prolia/Xgeva Injection, denosumab, 1 mg J1290 Kalbitor Ecallantide injection X 7/1/2011 J1300 Soliris INJECTION, ECULIZUMAB, 10 J1325 Flolan Epoprostenol injection J1438 Enbrel INJECTION, ETANERCEPT, 25 (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF- ADMINISTERED) J1458 Naglazyme Galsulfase injection J1459 Privigen GLOBULIN (PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (E.G., LIQUID), 500 J1460 Gamastan INJECTION, GAMMA GLOBULIN, 1CC J1556 Bivigam Injection, immune globulin (bivigam), 500 mg

5 Pharmacy Services 5 J1557 Gammaplex Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg J1559 Hizentra Hizentra injection X 7/1/2011 J1560 Gamastan INJECTION, GAMMA J1561 Gamunex, Gammunex-C, Gammaked GLOBULIN, 10CC GLOBULIN, (GAMUNEX/GAMUNEX- C/GAMMAKED), NONLYOPHILIZED (E.G., LIQUID), 500 J1562 Vivaglobin IVIG X 1/1/2012 J1566 GLOBULIN, INTRAVENOUS, Gammagard S/D / LYOPHILIZED (E.G., Carimune Nf POWDER), NOT OTHERWISE SPECIFIED, 500 J1568 Octagam INJECTION, OCTAGAM, 500 J1569 Gammagard Liquid GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NONLYOPHILIZED, (E.G., LIQUID), 500 J1572 Flebogamma GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NONLYOPHILIZED (E.G., LIQUID), 500 J1599 IVIG, NON-LYOPHILIZED, LIQUID, NOS X 7/1/2011 J1602 Simponi Aria Injection, golimumab, 1 mg, for intravenous use J1725 Makena Injection, hydroxyprogesterone caproate, 1 mg X J1740 Boniva INJECTION, IBANDRONATE SODIUM, 1 J1743 Elaprase Idursulfase injection J1744 Firazyr Injection, icatibant, 1 mg X 1/1/2013 J1745 Remicade INJECTION INFLIXIMAB, 10 X 5/1/2006 J1786 Cerezyme INJECTION, IMIGLUCERASE, 10 UNITS J1930 Somatuline Depot Lanreotide injection J1931 Aldurazyme Laronidase injection

6 Pharmacy Services 6 J1950 J2212 J2315 J2323 J2353 J2357 J2358 Lupron Relistor Vivitrol Tysabri Sandostatin LAR Xolair Zyprexa Relprevv INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 Injection, methylnaltrexone, 0.1 mg INJECTION, NALTREXONE, DEPOT FORM, 1 INJECTION, NATALIZUMAB, 1 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 INJECTION, OMALIZUMAB, 5 INJECTION, OLANZAPINE, X 1/1/2013 X 1/1/13 for CM; 2/1/13 for MA X 7/1/2011 LONG-ACTING, 1 J2426 Invega Sustenna Paliperidone palmitate inj X 7/1/2011 J2504 Adagen Pegademase bovine, 25 iu J2507 Krystexxa Injection, pegloticase, 1 mg X 1/1/2012 J2562 Mozobil PLERIXAFOR J2778 Lucentis INJECTION, RANIBIZUMAB, 0.1 J2793 Arcalyst RILONACEPT J2794 Risperdal Consta INJECTION, RISPERIDONE, LONG ACTING, 0.5 J2796 Nplate INJECTION, ROMIPLOSTIM, 10 MCG J2941 Genotropin SOMATROPIN X 1/1/2012 J3060 Elelyso Injection, taliglucerace alfa, 10 units J3262 Actemra INJECTION, TOCILIZUMAB, 1 J3285 Remodulin Treprostinil injection J3315 Trelstar INJECTION, TRIPTORELIN PAMOATE, 3.75 J3357 Stelara Ustekinumab injection J3385 Vpriv Velaglucerase alfa J7316 Jetrea Injection, ocriplasmin, mg J7321 Supartz/ Hyalgan DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA- ARTICULAR INJECTION, PER DOSE

7 Pharmacy Services 7 J7323 J7324 J7325 J7326 J7335 J7639 Euflexxa Orthovisc Synvisc/ Synvisc- One Hyaluronan "Gel- One" Qutenza Pulmozyme DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA- ARTICULAR INJECTION, 1 Hyaluronan or derivative, Gel- One, for intra-articular injection, per dose CAPSAICIN 8% PATCH, PER 10 SQ CM DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER X X 1/1/2011-7/1/2012 for MA 7/1/2011-1/1/2012 for MC J7686 Tyvaso Treprostinil, non-comp unit X 7/1/2011 J8562 Oforta Oral fludarabine phosphate J9155 Firmagon INJECTION, DEGARELIX, 1 X 1/1/2012 J9202 Zoladex GOSERELIN ACETATE IMPLANT, PER 3.6 J9216 Actimmune Interferon gamma 1-b J9217 Eligard LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 J9218 Lupron LEUPROLIDE ACETATE, PER 1 J9225 Vantas HISTRELIN IMPLANT (VANTAS), 50 J9226 Supprelin LA HISTRELIN IMPLANT J9310 Rituxan INJECTION, RITUXIMAB, 100 X 6/1/2007 Q2043 Provenge Sipuleucel-T auto CD54+ Q3028 Rebif Injection, interferon beta-1a, 1 mcg for subcutaneous use X 7/1/2014 Q4074 Ventavis Iloprost non-comp unit dose