Prior Authorization and Voluntary Preservice Determination Requests for Certain Pharmacy Drugs

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1 October 2016 Prior Authorization and Voluntary Preservice Determination Requests for Certain Pharmacy Drugs Important Changes We want to let you know that on November 14, 2016, we will change prior authorization and voluntary preservice determination submission processes, and change the entity who will manage select medical pharmacy drugs. Currently, Magellan Rx Management only performs prior authorization and voluntary preservice determination requests for participating physicians who buy and bill for drugs included in the Physician Administered Drug Program list of drugs that require prior authorization. Starting November 14, Magellan Rx Management will also review additional prior authorization and voluntary preservice determination requests for specific drug services that are currently managed by Florida Blue. Summary of changes effective November 14, 2016: All providers, including physicians, hospitals, ancillary and out-of-state providers, who buy and bill for medications, must submit voluntary preservice reviews through Magellan Rx Management instead of Florida Blue for the drugs included in the Physician Administered Drug Program list. Florida Blue will continue to manage drugs that are not included in this list. To ensure consistency, and reduce confusion about where to submit prior authorization or voluntary predetermination requests for drugs included in the Physician Administered Drug program list, all requests must be submitted to Magellan Rx Management instead of Florida Blue. This applies to drugs administered by all provider and facility types in the following care settings: office, home, outpatient hospital, ambulatory surgical center, ambulatory infusion suites, public health clinics, rural health clinics, and/or other outpatient settings. New medications may be added to the list of Physician Administered Drugs Program drugs periodically, so it is important to refer to this list in the provider manual on our website at floridablue.com. Medications for members enrolled in the following programs are excluded from management by Magellan Rx Management: Federal Employee Program, Medicare Supplement, when Medicare Part B is primary, and/or other Blue Plan members who receive services in Florida through the BlueCard program. Magellan Rx Management will provide these utilization management services on our behalf for members who are enrolled in the following health plans: BlueCare HMO (Health Options, Inc.) - all members BlueMedicare SM HMO - all members BlueOptions SM (NetworkBlue) BlueMedicare SM PPO

2 myblue (myblue network) BlueSelect (BlueSelect network) Group BlueChoice (Preferred Patient Care) Identifies the products above that require prior authorization for select plans (e.g., Qualified Health Plans, Affordable Care Act, etc.) within the specified product. The plans that do not require prior authorization are eligible for a Voluntary Preservice Determination Review. Magellan Rx Management will provide Voluntary Preservice Determination Reviews on our behalf for members who are enrolled in the following health plans: State Employees PPO Plan all members Traditional Indemnity plans all members BlueOptions SM (NetworkBlue) - for the plans that do not require prior authorization Miami-Dade Blue GoBlue all members Group BlueChoice (Preferred Patient Care) - for the plans that do not require prior authorization Individual BlueChoice (Preferred Patient Care) All prior authorizations/ voluntary preservice determination reviews for the drugs listed below will need to be submitted to Magellan Rx Management on and after November 14, How to obtain a preservice review You can obtain a preservice review by accessing Magellan Rx Management s secure website at ih.magellanrx.com or by calling them at (800) Please refer to Magellan s helpful step-by-step guide called Access Prior Authorizations for Magellan Rx Medications on the Florida Blue website at floridablue.com. You can also refer to Florida Blue s Manual for Physicians and Providers on our website for details about the Physician Administered Drug Program. The following table includes all drugs currently included in the Physician Administered Drug Program list that require review through Magellan Rx Management effective November 14, Code Code Name Description A9543 ZEVALIN IBRITUMOMAB TIUXETAN A9606 XOFIGO RADIUM RA223 DICHLORIDE THER J0129 ORENCIA SQ ABATACEPT J0178 EYLEA AFLIBERCEPT J0202 LEMTRADA ALEMTUZUMAB J0256 ARALAST NP ALPHA 1-PROTEINASE INHIBITOR J0256 ARALAST ALPHA 1-PROTEINASE INHIBITOR J0256 PROLASTIN-C ALPHA 1-PROTEINASE INHIBITOR J0256 ZEMAIRA ALPHA 1-PROTEINASE INHIBITOR J0257 GLASSIA ALPHA 1-PROTEINASE INHIBITOR J0585 BOTOX ONABOTULINUMTOXIN A J0586 DYSPORT ONABOTULINUMTOXIN A J0587 MYOBLOC ONABOTULINUMTOXIN B

3 J0588 XEOMIN ONABOTULINUMTOXIN A J0596 RUCONEST C-1 ESTERASE INHIBITOR (RECOMBINANT) J0597 BERINERT C1 ESTERASE INHIBITOR J0638 ILARIS CANAKINUMAB J0641 FUSILEV LEVOLEUCOVORIN J0717 CIMZIA CERTOLIZUMAB PEGOL J0800 HP ACTHAR CORTICOTROPIN J0881 ARANESP DARBEPOETIN ALFA J0885 EPOGEN EPOETIN ALFA J0885 PROCRIT EPOETIN ALFA J0888 MIRCERA EPOETIN BETA (non-esrd use) J0897 PROLIA DENOSUMAB J0897 XGEVA DENOSUMAB J1290 KALBITOR ECALLANTIDE J1300 SOLIRIS ECULIZUMAB J1442 NEUPOGEN FILGRASTIM J1447 GRANIX TBO-FILGRASTIM J1453 EMEND FOSAPREPITANT J1459 PRIVIGEN HUMAN IMMUNE GLOBULIN J1556 BIVIGAM HUMAN IMMUNE GLOBULIN J1557 GAMMAPLEX HUMAN IMMUNE GLOBULIN J1561 GAMMAKED HUMAN IMMUNE GLOBULIN J1561 GAMUNEX HUMAN IMMUNE GLOBULIN J1561 GAMUNEX-C HUMAN IMMUNE GLOBULIN J1566 CARIMUNE NF HUMAN IMMUNE GLOBULIN J1566 GAMMAGARD SD HUMAN IMMUNE GLOBULIN J1566 PANGLOBULIN NF HUMAN IMMUNE GLOBULIN J1568 OCTAGAM HUMAN IMMUNE GLOBULIN J1569 GAMMAGARD LIQUID HUMAN IMMUNE GLOBULIN J1572 FLEBOGAMMA HUMAN IMMUNE GLOBULIN J1599* Unclassified IVIG* HUMAN IMMUNE GLOBULIN J1602 SIMPONI ARIA GOLIMUMAB J1725 MAKENA HYDROXYPROGESTERONE CAPROATE J1740 BONIVA IBANDRONATE SODIUM J1745 REMICADE INFLIXIMAB J1786 CEREZYME IMUGLUCERASE J1930 SOMATULINE DEPOT LANREOTIDE J1950 LUPRON DEPOT LEUPROLIDE ACETATE J2323 TYSABRI NATALIZUMAB J2353 SANDOSTATIN LAR OCTREOTIDE DEPOT J2357 XOLAIR OMALIZUMAB J2469 ALOXI PALONOSETRON J2503 MACUGEN PEGAPTANIB SODIUM

4 J2505 NEULASTA PEGFILGRASTIM J2507 KRYSTEXXA PEGLOTICASE J2562 MOZOBIL PLERIXAFOR J2778 LUCENTIS RANIBIZUMAB J2783 ELITEK RASBURICASE J2796 NPLATE ROMIPLOSTIM J2820 LEUKINE SARGRAMOSTIM (GM-CSF) J3060 ELELYSO TALIGLUCERASE ALFA J3262 ACTEMRA TOCILIZUMAB J3315 TRELSTAR DEPOT TRIPTORELIN PAMOATE J3315 TRELSTAR LA TRIPTORELIN PAMOATE J3357 STELARA USTEKINUMAB J3380 ENTYVIO VEDOLIZUMAB J3385 VPRIV VELAGLUCERASE ALFA J3396 VISUDYNE VERTEPORFIN J3590 ENTYVIO NDC: (UNCLASSIFIED BIOLOGIC) J3489 ZOMETA/ RECLAST ZOLEDRONIC ACID J7311 RETISERT FLUOCINOLONE ACETONIDE, intravitreal implant J7312 OZURDEX DEXAMETHASONE, intravitreal implant J7313 ILUVIEN FLUCINOLONE ACETONIDE, intravitreal implant J7321 HYALGAN SODIUM HYALURONATE J7321 SUPARTZ SODIUM HYALURONATE J7323 EUFLEXXA SODIUM HYALURONATE J7324 ORTHOVISC HIGH MOLECULAR WEIGHT HYALURONAN INJECTION J7325 SYNVISC HYLAN G-F 20 J7325 SYNVISC ONE HYLAN G-F 20 J7326 GEL-ONE CROSS-LINKED HYALURONATE J7327 MONOVISC HIGH MOLECULAR WEIGHT HYALURONAN INJECTION J7328 GEL-SYN HYALURONAN/ DERIVATIVE J9019 ERWINAZE ASPARAGINASE J9025 VIDAZA AZACITIDINE J9032 BELEODAQ BELINOSTAT J9033 TREANDA BENDAMUSTINE J9033 BENDEKA BENDAMUSTINE J9035 AVASTIN (oncology BEVACIZUMAB use) J9039 BLINCYTO BLINATUMOMAB J9041 VELCADE BORTEZOMIB J9042 ADCETRIS BRENTUXIMAB VEDOTIN J9043 JEVTANA CABAZITAXEL

5 J9047 KYPROLIS CARFILZOMIB J9055 ERBITUX CETUXIMAB J9155 FIRMAGON DEGARELIX, 1MG J9171 DOCEFREZ DOCETAXEL J9171 TAXOTERE DOCETAXEL J9179 HALAVEN ERIBULIN J9202 ZOLADEX GOSERELIN ACETATE J9217 ELIGARD LEUPROLIDE ACETATE J9217 LUPRON DEPOT LEUPROLIDE ACETATE J9225 VANTAS HISTRELIN ACETTE J9226 SUPPRELIN LA HISTRELIN ACETATE J9228 YERVOY IPILIMUMAB J9262 SYNRIBO OMACETAXINE MEPESUCCINATE J9263 ELOXATIN OXALIPLATIN J9264 ABRAXANE PACLITAXEL J9271 KEYTRUDA PEMBROLIZUMAB J9299 OPDIVO NIVOLUMAB J9301 GAZYVA OBINUTUZUMAB J9302 ARZERRA OFATUMUMAB J9303 VECTIBIX PANITUMUMAB J9305 ALIMTA PEMETREXED J9306 PERJETA PERTUZUMAB J9307 FOLOTYN PRALATEXATE J9308 CYRAMZA RAMUCIRUMAB J9310 RITUXAN RITUXIMAB J9330 TORISEL TEMSIROLIMUS J9354 KADCYLA ADO-TRASTUZUMAB J9355 HERCEPTIN TRASTUZUMAB J9400 ZALTRAP ZIV-AFLIBERCEPT J9999* NOC* NOC ANTINEOPLASTIC* Q2043 PROVENGE SIPULEUCEL-T AUTOLOGOUS CD54+ CELLS Q2049 LIPODOX DOXORUBICIN LIPOSOMAL Q2050 DOXIL DOXORUBICIN LIPOSOMAL Q5101 ZARXIO FILGRASTIM-SNDZ Q5102 INFLECTRA INFLIXIMAB, BIOSIMILAR Important note: The table above lists new medications added to the program effective November 14, For a complete list of drugs included in the Physician Administered Drug Program, please refer to the Manual for Physicians and Providers on our website at floridablue.com, and select the Physician Administered Drug Program section